FS Form 5236 Claim for Proceeds of a Check

RESET
For official use only:
Customer Name

Customer No.

FS Form 5236
Department of the Treasury
Bureau of the Fiscal Service
(Revised August 2015)

OMB No. 1530-0042

CLAIM FOR PROCEEDS OF A CHECK

IMPORTANT: Follow instructions in filling out this form. You should be aware that the making of any false, fictitious, or fraudulent claim or
statement to the United States is a crime that is punishable by fine and/or imprisonment.
PRINT IN INK OR TYPE ALL INFORMATION

1.

RETURN THIS FORM TO:
Treasury Retail Securities Site, PO Box 214, Minneapolis, MN 55480-0214
Treasury Retail Securities Site, PO Box 2186, Minneapolis, MN 55480-2186
Treasury Retail Securities Site, PO Box 7015, Minneapolis, MN 55480-7015
Treasury Retail Securities Site, PO Box 9150, Minneapolis, MN 55480-9150
Bureau of the Fiscal Service, PO Box 426, Parkersburg, WV 26106-0426

2.

CHECK IDENTIFICATION: (To be completed by one of the above agencies.)
Check No.:

Date:

Amount:

Check Inscription:
(Name/Names)
(Address)

Checking Account No:
Issuing Agent:
Payment Reason:
Investor Account No. (if applicable):
3.

Check Color:

SUPPORTING INFORMATION – In support of your claim for the proceeds of the above-described check, you must provide the
information requested in this item.
a. Did you receive this check?

Yes

No

b. Did you sign your name on this check?

Yes

No

c. Did you cash this check?

Yes

No

d. Was this check cashed with your permission?

Yes

No

e. Did you deposit this check in a bank, credit union, or other organization?

Yes

No

f. Did someone else deposit this check to an account that you could use?

Yes

No

g. Did you receive any money or benefit in any way from this check (i.e., household expenses, child support, etc.)?
Yes
No
If Yes, explain and include amount, if known.

h. Is your present name different from that on the face of the check?

Yes

No

If Yes, explain why.

i. If you're making a claim for this check and it is not made out to you, show your relationship to the payee and explain why he/she
can't sign. (Appropriate documentation must be provided – see Item 3i in the Instructions.)

j. Did you ever live or receive mail at the address on the front of this check?

Yes

No

k. Provide the mailing address you used on the date the check was issued.

l. If you moved, did you advise the Post Office and the agency which authorized payment?

Yes

No

m. If anyone other than you had the opportunity to receive your mail, provide his/her name and address.

n.

If you lost any identification which could have been used by someone else to cash the check, explain.

o.

If you have any information concerning the cashing of the check, explain.

p. Where did you usually cash or deposit your checks at the time this check was cashed?
4.

SIGNATURE(S):

You must wait until you are in the presence of a certifying officer to sign this form.
Sign here:

Sign here:
(Second Payee's Signature)

(Payee's Signature)

(Number and Street or Rural Route)

(City)

(State)

(Number and Street or Rural Route)

(ZIP Code)

(City)

(State)

(Social Security Number)

(Social Security Number)

(Daytime Telephone Number)

(Daytime Telephone Number)

(E-Mail Address)

(E-Mail Address)

(ZIP Code)

To assist in handwriting comparisons, please sign your name three additional times.

(Payee's Signature)

(Second Payee's Signature)

(Payee's Signature)

(Second Payee's Signature)

(Payee's Signature)

(Second Payee's Signature)

Certifying Officer – Each individual must sign in your presence.
Complete the certification and affix your stamp or seal. Brokers must use a Medallion Stamp.
I CERTIFY that

,

I CERTIFY that

whose identity is known or was proven to me, personally
appeared before me this

day of

,

whose identity is known or was proven to me, personally
,

appeared before me this

day of

,

(Month)

, at
(Year)

(Month)

,
(City)

, at

(State)

(Year)

and signed this form.

(State)

and signed this form.

(Signature of certifying officer)

(OFFICIAL STAMP
OR SEAL)

,
(City)

(Signature of certifying officer)

(OFFICIAL STAMP
OR SEAL)

(Title of certifying officer)

(Address)

(Title of certifying officer)

(Address)
2

FS Form 5236

INSTRUCTIONS
"You" on this form refers to the payee(s) or his/her/their authorized representative.
USE OF FORM – You can use this form to make a claim for the proceeds of either a fiscal agency check or a Treasury
check which is shown to have been paid but for which you never received the funds. If it is later determined that you
cashed the original and any settlement check(s), the overpayment must be properly refunded. Failure to do so could result
in legal action. Be sure to include the Check Identification information from Item 2 with any refund. (You may use the area
at the bottom of Page 4 to document this information for your records. You may also want to keep a copy of the completed
form.)
Before completing this form:


Examine the copy of the cashed check, especially the handwritten and/or stamped endorsements on the back. Pay
particular attention to the date of the check.



If the copy of the cashed check is not the check you are missing, or if you have a question about the check amount,
contact the appropriate Federal Reserve Bank or the Bureau of the Fiscal Service (whichever office provided you with
this form).



If the copy of the cashed check shows that the check was deposited at your bank, credit union, savings and loan, or
other financial institution, take the copy of the check to that institution and ask them to verify that your account was not
credited. If you are unable to settle this matter with your financial institution, complete and return this form and the
copy of the cashed check.



If you signed the check or the check was cashed with your permission or if, for any other reason, you do not want to
make a claim for the amount of the check, do NOT return this form.



If you have already received reimbursement for the check, do NOT return this form.

If you did not sign the check, did not give someone else permission to cash the check, or did not benefit in any way from the
redemption of the check, complete and sign this form, as specified below.
COMPLETION OF FORM – Print clearly in ink or type all information requested. If more space is needed for any item, use
a plain sheet of paper and attach it to this form.
ITEM 1.

This item is completed by the Servicing Office, advising you where to return the completed form.

ITEM 2.

This item is completed by the Servicing Office, identifying the check in question.

ITEM 3.

Furnish all requested information:

 a.

Indicate whether you received the check.

 b.

Indicate whether you signed your name on the check.

 c.

Indicate whether you cashed the check.

 d.

Indicate whether the check was cashed with your permission.

 e.

Indicate whether you deposited the check in a bank, credit union, or other organization.

 f.

Indicate whether someone else deposited the check to an account that you can use.

 g.

Indicate whether you received any money or benefit in any way from this check. If Yes, fully
explain and include the amount received, if known.

 h.

Indicate whether your present legal name is different from that on the face of the check.
provide your current legal name and explain how the change of name occurred.

 i.

If you're making a claim for this check and you are not a payee, show your relationship to the
payee and explain why he/she can't sign this form. Appropriate documentation must be submitted
with the form (i.e., a certified copy of the Letters of Guardianship or Conservatorship, a certified
copy of Letters of Administration, a copy of the Power of Attorney signed in accordance with State
law, etc.)

 j.

Indicate whether you ever lived or received mail at the address shown in the check inscription.

 k.

Provide the complete mailing address you used on the date the check was issued (the date is
shown in Item 2).

 l.

If you have moved since the check was issued, indicate whether you advised the Post Office and
the agency which authorized the payment.
3

If Yes,

FS Form 5236

ITEM 4.

 m.

If someone other than you had the opportunity to receive your mail, provide his/her name and
address.

 n.

If you lost any identification which could have been used by someone else to cash the check,
provide a full explanation, including the type(s) of identification.

 o.

Provide any information you have concerning the cashing of the check.

 p.

Provide the name and address of the financial institution where you usually cashed or deposited
your checks at the time the check was issued (the date is shown in Item 2).

Sign the form in ink in all the spaces provided and furnish your complete home address, Social Security
Number, daytime telephone number, and e-mail address, if applicable. If there are two payees, both must
sign the form. Each payee's signature must be certified (see CERTIFICATION below).

CERTIFICATION – You must appear before and establish identification to the satisfaction of an authorized certifying officer
and sign the form in the officer’s presence. The certifying officer must complete the certification forms provided and affix the
seal or stamp which is used when certifying requests for payment. Brokers must use a Medallion Stamp. Authorized
certifying officers are available at banking institutions, including credit unions, in the United States. For a complete list of
such officers see Department of the Treasury Circular Nos. 300 and 530, current revisions, and Public Debt Series
Nos. 3-80 and 2-98.
WHERE TO SEND – Send the completed form and the copy of the cashed check to the office shown in Item 1. If no box is
checked in Item 1, send the form to the Servicing Office which sent it to you.
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
The collection of the information you are requested to provide on this form is authorized by 31 U.S.C. CH. 31 relating to the public debt of the United
States. The furnishing of a Social Security Number, if requested, is also required by Section 6109 of the Internal Revenue Code (26 U.S.C. 6109).
The purpose of requesting the information is to enable the Bureau of the Fiscal Service and its agents to issue securities, process transactions, make
payments, identify owners and their accounts, and provide reports to the Internal Revenue Service. Furnishing the information is voluntary; however,
without the information, the Fiscal Service may be unable to process transactions.
Information concerning securities holdings and transactions is considered confidential under Treasury regulations (31 CFR, Part 323) and the Privacy Act.
This information may be disclosed to a law enforcement agency for investigation purposes; courts and counsel for litigation purposes; others entitled to
distribution or payment; agents and contractors to administer the public debt; agencies or entities for debt collection or to obtain current addresses for
payment; agencies through approved computer matches; Congressional offices in response to an inquiry by the individual to whom the record pertains;
as otherwise authorized by law or regulation.
We estimate it will take you about 30 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 the correct address
shown in Item 1.

(Detach and keep for your records)

Check No.:

Date:

Amount:

Check Inscription:
(Name/Names)
(Address)

Checking Account No:
Issuing Agent:
Payment Reason:
Investor Account No. (if applicable):

Check Color:

4

FS Form 5236