Instructions for FSA-325
APPLICATION FOR PAYMENT OF AMOUNTS DUE PERSONS WHO HAVE DIED, DISAPPEARED, OR HAVE BEEN DECLARED INCOMPETENT
This form is used to request payments that were earned by another producer when the producer that earned the payment dies, is declared incompetent, or disappears. This request must be made prior to issuance of the payment by FSA or before an issued payament is negotiated.
Submit the original of the completed form in hard copy or facsimile to your FSA servicing office.
Producers must complete items 5 through 17.
Items 1-4 are for FSA use only.
Items 5-17
Fld Name / |
Instruction |
5 Represen-tation Statement |
Please read. |
6 Name |
Enter the name of the person who died, disappeared, or was declared incompetent. |
7 Disposition of Producer |
Check the applicable box and enter the date person died or was declared incompetent or approximate date of disappearance. |
8 Un-negotiated Check or Certificate Numbers |
Enter the number of all un-negotiated checks or certificates. If none have been issued, enter "none." |
9 Amount and Date |
Enter the amount of the un-negotiated check or certificate and the date issued. Leave the date blank if the payment has not been issued. |
10 Certification Statement |
Please read. |
11 Name and Address |
If the person is deceased enter the name and address of the first person in the following categories in which there is an eligible applicant:
If the person has disappeared, enter the name of the person in the following categories in which there is an eligible applicant:
If the person has been declared incompetent, and: A) There is a guardian, committee, or conservator, enter the name and address of the guardian, committee, or conservator. B) There is no guardian or committee and the payment is not more than $1000.00 enter name of eligible applicant as they fit in each category:
C) If the amount is over $1000.00 enter the person as authorized under State law to receive the payment. |
12 Relationship or Capacity |
Enter the relationship or capacity of the name(s) entered in item 11. |
13 Name of Minor or Incompetent |
If any of the persons listed in item 11 is a minor or is under any legal disability, enter the name of the person and the nature of disability, if applicable, |
14 Name and Address of Represent-ative |
Enter the name and address of the person representing the minor or incompetent person entered in item 13 (guardian, custodian, etc.). |
15 and 16 |
Please read. |
17 Signatures |
All persons listed in item 11 must sign and date this document. |
File Type | application/msword |
File Title | Instructions For FSA-18 |
Author | maryann.ball |
Last Modified By | maryann.ball |
File Modified | 2009-12-07 |
File Created | 2009-12-07 |