Form FS Form 6314 FS Form 6314 Assignment Form

RESET FORM

OMB No. 1530-0011
ASSIGNMENT

KNOW ALL MEN, BY THESE PRESENTS: That I,
(name of awardholder-assignor)
(state capacity when other than an individual capacity) residing at
_for valuable consideration, the receipt whereof is hereby acknowledged, do hereby
assign, transfer, and set over unto

of my
(percentage assigned)

(name of assignee)

right, title and interest in and to the unpaid balance of the award of the Foreign Claims Settlement Commission of the United
States to

, Claim No.

,

(name of original awardee)
Decision No.

. I hereby request and direct the Secretary of the Treasury to make payment directly to
at

.

(assignee’s name)

(address of assignee)

IN WITNESS WHEREOF, I have hereunto set my hand and seal this
at

day of

_, 20

.

(signature of awardholder-assignor)
ACKNOWLEDGEMENT
STATE OF

_)

COUNTY OF

_)

ss:

Before me,
State of

in and for the County of

,

, on this day personally appeared

known to me to be the person _ _____ whose name _ _____ subscribed to the foregoing instrument and acknowledged to me
that ______ he ______ executed the same for the purposes and consideration therein expressed.
GIVEN under my hand and seal of office, this

day of

, A.D. 20

_.

(signature of Notary or other official)

(Seal)

My commission expires

.

The estimate average burden associated with this collection is 30 minutes per respondent or recordkeeper, depending on individual
circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed 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 the address provided in the instructions received with the form.

FS Form 6314

DEPARTMENT OF THE TREASURY
BUREAU OF THE FISCALSERVICE