Application for payment of amounts due persons who have died, disappeared, or declared incompetent

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 / Item No.	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: Administrator or executor of the estate Surviving spouse Surviving sons and daughters(including adopted children) Surviving father and mother Surviving brothers and sisters Such heirs(next of kin) If the person has disappeared, enter the name of the person in the following categories in which there is an eligible applicant: Conservator or liquidator of his/her estate Spouse Adult son or daughter or grandchild Mother or father Adult brother or sister Such person as may be authorized under State law. 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: Spouse Adult son, daughter, or grandchild Mother or father Adult brother or sister Such person as may be authorized under State law 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.

 

Item 18 is for FSA use only.