FS Form 1201W Request for Payment of Federal Benefits by Check

Ruquust for Paymunt of Fudural BunBfits by Chuck

OMB No. 1510-0077

FS Form 1201W (March 2014) Previous versions obsolete.
Federal law (31 U.S.C. 3332 and 31 CFR 208) requires that all Federal benefit and other nontax payments be made electronically.

, you must explain

for a wy submitting this certified Request for Waiver to the U.S. Department

To receive your payments by check, you must explain how you qualify for a waiver by submitting this certified Request for Waiver to the U.S. Department
of the
of the Treasury.
Dl RECTIONS • Complete boxes A, B, C , and D.
• This Request for Waiver must be signed by the payment
recipient. In cases where a representative payee has
been designated, the representative payee is the
payment recipient who should sign the form.

A. FEDERAL PAYMENT RECIPIENT INFORMATION
(print name{s] and address exactly as they appear on your benefit check)

NAME OF THE PERSON ENTITLED TO GOVERNMENT BENEFITS (BENEFICIARY)

REPRESENTATIVE PAYEE?
Yes O
(IFYesenter No
name at ng'lt)

0

NAME OF REPRESENTATIVE PAYEE

ADDRESS (street, route, PO. Box, apartment number)

CITY (or APO I FPO)

STATE

ZIP CODE

DAYTIME TELEPHONE NUMBER

• Submit the completed original form to th e U.S. Treasury
Electronic Payment Solution Center at the address found
at the bottom of this form.
• Incomplete forms cannot be processed.

B. WAIVER REQUEST

(one form for each check received)

TYPE OF FEDERAL BENEFIT:
Receiving payments electronically will impose a hardship on me
because (check one):

D

I am unable to manage an account at a finan cial in stitution or a
Direct Express® card account due to a mental impairment.

D

I am unable to manage an account at a financial institution or a
Direct Express® card because I live in a remote geographic
location lacking the infrastructure to support electronic financial
transactions.

D

I was born on or before May 1, 1921.
My dale of birth is:
mml dd/yy

SOCIAL SEOJRITY N.JMJER OF F£RSON ENTITLED TO GOVERt\MENT BENEFITS Q:JENEFICIARY)

DDD-DD-DDDD
CLAIM NUMBER

C. REQUEST FOR WAIVER SUPPORTING INFORMATION
Please write 1-2 sentences to explain why your mental impairment or remote geographic location makes you unable to receive payments electronically.

D. CERTIFICATION
I certify that all of the statements in this Request for Waiver are true. I understand that any person who knowingly or willfully m akes false or fraudulent
statements or representations to the United states gov ernment in connection with this Request for Waiver may be subject to fines and I or
imprisonment (18 U.S.C. §§ 1001).
SIGNATURE

Be sure to complete all sections
of this form. Otherwise, the form
cannot be processed.

Return the completed form to:

U.S. Treasury
Electronic Payment Solution Center
P.O. Box 650015
Dallas, TX 75265-0015

DATE

PRIVACY ACT NOTICE: Coll ection of th e information in this Request for Waiver is authorized by
5 U.S.C. § 552a, 31 U.S.C. § 3332(g), and Executive Order 9397 (November 22, 1943). Your social
security number and the other information requested will allow the federal government to process your
request for a waiver. Your social security number is requested to ensure the accurate identification and
retention of records pertaining to you and to distin guish you from other recipients of federal payments.
This information will be disclosed to th e Department of the Treasury and its fiscal and financial agents,
and other federal agencies, as necessary to process your request for a waiver. This information may
also be disclosed to a court, congressional committee or another government agency as authorized
or required to verify your receipt of federal payments. Although providing the requested information
is voluntary, your request for waiver cannot be processed without it.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The time required to complete this information collection is estimated to
average 20 minutes, including the time to review instructions, search existing data resources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Comments concerning the accuracy of the
time estimate and suggestions for reducing this burden should be directed to the Department of the Treasury, Bureau of the Fiscal Service, Washington, DC 20005.