Form FS Form 5135 FS Form 5135 Voucher for Payment of Awards Certified By The Mixed Cla

OMB No 1530-0012
Voucher No.

VOUCHER FOR PAYMENT OF AWARDS
CERTIFIED BY THE MIXED CLAIMS COMMISSION,
UNITED STATES AND GERMANY OR THE
FOREIGN CLAIMS SETTLEMENT COMMISSION
or for the payment of accounts divested under Title II of the
International Claims Settlement Act of 1949, as amended.
RETURN TO:

BUREAU OF THE FISCAL SERVICE
DEPARTMENT OF THE TREASURY
3700 EAST-WEST HIGHWAY, RM 6F03
FOREIGN CLAIMS SECTION
HYATTSVILLE, MD 20782

NAME OF PAYEE
ADDRESS
Docket or
Claim No.

Claim of

XX

$

International Claims Settlement Act of 1949, as amended

Title II of the War Claims Act of 1948, as amended

The Settlement of War Claims Act of 1928, as amended
NOTICE

FINES, PENALTIES, AND FORFEITURES AND IMPOSED BY LAW FOR MAKING OF FALSE OR FRAUDULENT CLAIMS AGAINST THE
UNITED STATES OR MAKING OF FALSE STATEMENTS IN CONNECTION THEREWITH. (31 U.S.C.231, 18 U.S.C. 1001)
STATEMENT
I state that I am personally entitled, or duly authorized on behalf of the estate, partnership or corporation which is entitled, to make claim for and to
receive the award (share) payment described on this voucher in the following capacity, and I hereby make claim for such payment.

Date

Signature

Address

Taxpayer Identification Number / SSN is required to make payment:

APPROPRIATION:

Date

FS Form 5135

Paid by
Check No.
& Symbol

Schedule No.

Department of the Treasury | Bureau of the Fiscal Service

on United States
Treasury in favor
of payee named
above.

August 2015