FMS 1133-A Claim Against the United States for Proceeds of a Govern

PAYEE INSTRUCTIONS FOR COMPLETING FORM FMS 1133-A, CLAIM AGAINST THE UNITED STATES
FOR THE PROCEEDS OF A U.S. TREASURY PAYMENT
U.S. TREASURY
OMB No. 1530-0010
Claims Document: 1234
Bensalem, PA 19154
Date:

JAMIE SMITH
170 WEST 20TH ST
BALTIMORE, MD 21218

You are receiving this letter because you recently filed a claim with the Social Security Administration (SSA).
You told us that a recent SSA electronic benefit payment was not received.
We are working to resolve this issue and need some additional information from you.
Our records show that a payment was made to the person and account listed below. If this information
is not correct, fraud may be involved. Please carefully review the following information, then complete the
included FMS 1133-A Claim Form (4 pages) and return the completed form to the address at the bottom of
this page.
Payee Name:

Jamie Smith

Payee ID (SSN):

***-**-6789

Agency Paid By:

Social Security Administration

Payment Amount:

$566.00

Payment Date:

7/1/2014

Financial Institution:

First National Bank

Account Number:

**** **** **** 3456

Note: If you use a pre-paid card to receive benefits, the financial institution can be found on the back of the card.

If your banking information changes in the future, please send your updated information to the address at the
bottom of this page.

ACTION REQUIRED:
1. Please keep this page for your records.
2. Answer all questions on the included form truthfully and to the best of your knowledge. If you have
questions while completing the form, please call 1-855-868-0151, option 1 for help.

IMPORTANT: Failure to complete and return this form may lead SSA to find that you have
been overpaid. SSA may seek to recover that overpayment from you.

3. Initial top of each page and return the completed / signed form to the address below. You can expect
a resolution within 30 days of receipt.

Philadelphia Financial Center
Non-Receipts Section
P.O. Box 603
Bensalem, PA 19154

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CLAIM AGAINST THE UNITED STATES FOR THE
PROCEEDS OF A GOVERNMENT PAYMENT – FMS 1133-A CLAIM FORM
Your Social Security Number and other information requested will allow the Department of the Treasury to process your claim for the
proceeds of a government payment. The collection of information is made pursuant to the Department of the Treasury’s authority to
consider your claim, which is found at Title 31 of the Code of Federal Regulations. Parts 210. Your social security number will be used
to ensure the accurate identification and retention of records pertaining to you and to distinguish you from other claimants. Furnishing
your social security number and the other requested information is voluntary. However failure to provide any part of the requested
information may delay the processing of your claim.

Payee Name:
Payee ID (SSN):
Agency Paid By:

JAMIE SMITH
170 WEST 20TH ST
BALTIMORE, MD 21218

Payment Amount:
Payment Date:

Jamie Smith
***-**-6789
Social Security
Administration
$566.00
7/1/2014

Answer all of the following questions truthfully and to the best of your knowledge.
Please select ONE answer for each question.
WARNING: Title 18, Sec 287, US Code: Whoever makes or presents to any person or officer in the civil, military or naval service, of the
United States, or to any department or agency thereof, any claim upon or against the United States, or to any department or agency
thereof knowing such claim to be false, fictitious, or fraudulent, shall be fined not more than $10,000 or imprisoned not more than five
years, or both.

1. Did you receive the payment listed in this letter?
 No, I have not received it yet.
 Yes, I did receive it. Please continue to complete and return this entire form.
2. I signed up for my benefits to be…
 Deposited into my bank account:
Financial Institution:
______________________________________________
Account Number:

______________________________________________

 Loaded onto my pre-paid card:
Financial Institution:
______________________________________________
Pre-paid Card Number: ______________________________________________
Note: If you use a pre-paid card to receive benefits, the financial institution can be found on
the back of the card. A pre-paid card is a card that has money stored directly on it and is not
linked to your personal bank account.
 Sent to me by paper check.

Date:

Claims Document: 1234

PAGE 1 
 FMS Form 1133‐A 

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3. Were any expenses paid for you with this payment, such as for child support or to an assisted living
facility? These expenses may have been paid on your behalf or removed due to a wage garnishment
(money taken out of your earnings to pay a debt).
 No, no expenses were paid for me.
 Yes, some expenses have been paid for me with this payment.
If yes, please describe the expenses that were paid for you with this payment:
____________________________________________________________________
____________________________________________________________________
4. Did you authorize anyone to use your name or personal information to apply for your benefit payment,
open a bank account, or receive a pre-paid card for this payment?
 No, I did not authorize anyone.
 Yes, I authorized the following person:
Name:

______________________________________________________

Address: ______________________________________________________
______________________________________________________
Relationship:

______________________________________________________

If there are any additional authorized persons, please provide their name and
relationship to you:
___________________________________________________________________
___________________________________________________________________

5. Do you know of any unauthorized person who may have received this payment?
 No, I do not know who received this payment.
 Yes, the following person may have received it instead of me:
Name:

______________________________________________________

Address:

______________________________________________________
______________________________________________________

Relationship:

______________________________________________________

If there are additional unauthorized persons, please provide their name and
relationship to you:
____________________________________________________________________
____________________________________________________________________

Date:

Claims Document: 1234

PAGE 2 
 FMS Form 1133‐A 

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6. In the past year, has your identification, such as your driver’s license, been misplaced, lost, or stolen?
 No, I have not lost my identification.
 Yes, my identification has been lost in the past year.
If yes, please describe:
____________________________________________________________________
____________________________________________________________________
7. In the past year, has your identity been stolen? Stolen identities, such as your name or social security
number, can be used to open a credit card or to sign up for benefits in your name.
 No, my identity has not been stolen.
 Yes, my identity was stolen in the past year.
If yes, please describe:
____________________________________________________________________
___________________________________________________________________
8. In the past year, have you filed a police report related to your identity being stolen or about this missing
payment?
 No, I have not filed any police reports.
 Yes, I filed a police report about identity theft or about this payment in the past year.
If yes, please describe:
____________________________________________________________________
____________________________________________________________________
9. In the past year, have you set a credit fraud alert on your credit reports? A credit fraud alert is a
warning to credit agencies that your identity may have been put at risk.
 No, I have not set a credit fraud alert.
 Yes, I set a credit fraud alert on my credit reports in the past year.
If yes, please provide the credit fraud alert number(s):
____________________________________________________________________
____________________________________________________________________

Date:

Claims Document: 1234

PAGE 3 
 FMS Form 1133‐A 

Initial_____________ 

10. Is there any other information available about your account, benefits, or payments that will help us to
resolve this specific missing payment? Please include any errors or inconsistencies you noticed in your
payment information in this letter.
 No, I have no further information.
 Yes, there is more information regarding this missing payment.
If yes, please describe:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
WARNING: Title 18, Sec 287, US Code: Whoever makes or presents to any person or officer in the civil, military or naval service, of
the United States, or to any department or agency thereof, any claim upon or against the United States, or to any department or
agency thereof knowing such claim to be false, fictitious, or fraudulent, shall be fined not more than $10,000 or imprisoned not more
than five years, or both.

I certify that I answered all of the questions truthfully and to the best of my knowledge.

Signature:

_______________________________________

Date: ___________

Address:

____________________________________________________________

City/State/Zip: ____________________________________________________________

Telephone Number: _______________________________________________________

Please return this signed and completed FMS 1133-A Claim Form to the following address:

Philadelphia Financial Center
Non-Receipts Section
P.O. Box 603
Bensalem, PA 19154
You can expect a resolution within 30 days of receipt.
Be sure to keep the first page (Payee Instructions) for your records.
Notice Under the Paperwork Reduction Act:
We estimate it will take you about 10 minutes to complete this form. However, you are not required to provide information requested
unless a valid OMB control number is displayed on the form. Any comments or suggestions regarding this form should be sent to the
Bureau of the Fiscal Service, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form to the above
address; send to correct address shown in “Where to send” in the Instructions.

Date:

Claims Document: 1234

PAGE 4 
 FMS Form 1133‐A