Form FS Form 2066 FS Form 2066 Application By Survivors For Payment Of Bond Or Check Is

RESET
For official use only:
Customer Name
FS Form 2066
Department of the Treasury
Bureau of the Fiscal Service
(Revised March 2018)

Case No.
OMB No. 1530-0038

APPLICATION BY SURVIVORS FOR PAYMENT OF BOND
OR CHECK ISSUED UNDER THE ARMED FORCES
LEAVE ACT OF 1946, AS AMENDED

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

The undersigned, as survivors entitled under the terms of the Armed Forces Leave Act of 1946, as amended, and pursuant to Treasury
Department Circular No. 793, Revised, as amended, request immediate payment of the bond and/or check hereinafter described, the
owner or payee of which is deceased; we certify the following statements as to the bond or check, the deceased owner or payee and his
survivors on the date of his death, are full, true, and correct.
1. BOND OR CHECK – If both bond and check are unpaid, describe both:
Bond Number

Amount

Check Number

Amount

Bond Number

Amount

Check Number

Amount

2. DECEASED OWNER OR PAYEE – Complete the deceased owner or payee information below. The submission of the death certificate
or photocopy thereof will be necessary.
Date of Death
(Include month, day and year)

Name

Marital Status (At the time of death)

Married?

Legal Residence At the time of Death
(Complete address)

Divorced?

Single?

Widowed?

3. CLASS OF SURVIVORS (You must complete each question.)

•

Surviving Spouse and/or Children?

Yes

No

•

Parents?

Yes

No

•

Brothers and Sisters?

Yes

No

•

Children of Deceased Brothers and Sisters?

Yes

No

4. SURVIVORS – Describe the members of the first class marked “Yes” above who were living at the date of death of the deceased owner.
A. Persons now living:
Name

Date of
Birth

Relationship

Address

B. Persons who were living when decedent died but who have since died:
Name

Age at
Death

Date of Death

Married or Single
at Death

Relationship

5. PERSONS UNDER LEGAL DISABILITY – The persons listed in Item 4A who are under legal disability are:
Name

Legal Disability

Name of Representative

Capacity

6. APPLICANT ON BEHALF OF OTHERS (See Item 6 in the instructions.) – If applicant is not listed above, but is applying on behalf of one
or more listed above, complete the following:
Name

Application Made
on Behalf of

Address

Relationship or
Basis of Interest

SIGNATURES – You must wait until you are in the presence of a certifying officer to sign this form.

(Signature)

(Daytime Telephone No.)

(Signature)

(Daytime Telephone No.)

(Signature)

(Daytime Telephone No.)

(Signature)

(Daytime Telephone No.)

(Signature)

(Daytime Telephone No.)

(Signature)

(Daytime Telephone No.)

Applicant to contact:

if additional information is necessary.
(Name, Daytime Telephone Number, and E-Mail Address)

CERTIFICATION – All signatures must be certified. See the instructions.
Certifying Officer – The individuals must sign in your presence. Complete the certification and affix your stamp or seal.
I CERTIFY that

, whose identity is known or was proven

to me, personally appeared before me this

day of

,

,
(Year)

(Month)

, and signed this form.

at
(City)

(State)
(Signature and Title of Certifying Officer)

(OFFICIAL STAMP
OR SEAL)

(Number and Street or Rural Route)

(City)

I CERTIFY that

(State)

(ZIP Code)

, whose identity is known or was proven

to me, personally appeared before me this

day of

,

,
(Year)

(Month)

, and signed this form.

at
(City)

(State)
(Signature and Title of Certifying Officer)

(OFFICIAL STAMP
OR SEAL)

(Number and Street or Rural Route)

(City)

2

(State)

(ZIP Code)

FS Form 2066

I CERTIFY that

, whose identity is known or was proven

to me, personally appeared before me this

day of

,

,
(Year)

(Month)

, and signed this form.

at
(City)

(State)
(Signature and Title of Certifying Officer)

(OFFICIAL STAMP
OR SEAL)

(Number and Street or Rural Route)

(City)

I CERTIFY that

(State)

(ZIP Code)

, whose identity is known or was proven

to me, personally appeared before me this

day of

,

,
(Year)

(Month)

, and signed this form.

at
(City)

(State)
(Signature and Title of Certifying Officer)

(OFFICIAL STAMP
OR SEAL)

(Number and Street or Rural Route)

(City)

I CERTIFY that

(State)

(ZIP Code)

, whose identity is known or was proven

to me, personally appeared before me this

day of

,

,
(Year)

(Month)

, and signed this form.

at
(City)

(State)
(Signature and Title of Certifying Officer)

(OFFICIAL STAMP
OR SEAL)

(Number and Street or Rural Route)

(City)

I CERTIFY that

(State)

(ZIP Code)

, whose identity is known or was proven

to me, personally appeared before me this

day of

,

,
(Year)

(Month)

, and signed this form.

at
(City)

(State)
(Signature and Title of Certifying Officer)

(OFFICIAL STAMP
OR SEAL)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

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 correct address shown in "WHERE TO SEND" in the
Instructions.

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FS Form 2066

INSTRUCTIONS
USE OF FORM – This form is to be used to request payment of an Armed Forces Leave Bond or check issued under Section 6 of the Armed Forces
Leave Act of 1946, as amended, where the owner died without assigning the bond to the Administrator of Veterans Affairs prior to payment, or without
presenting the check for payment. The Act provides that bonds or checks in the name of a now-deceased owner or payee will be paid only to the
decedent’s survivors by the Secretary of the Treasury, upon their request and application, to the first of the following class of survivors who were living at
the date of the decedent’s death, in equal shares:
•
Surviving spouse and/or children,
•
Parents,
•
Brothers and Sisters, and
•
Children of Deceased Brothers and Sisters.
Payment will not be made to the members of a particular class of survivors if a member of a prior class was living at the date of the decedent’s death.
Payment will not be made to an administrator, executor, or creditor of the decedent’s estate. Survivorship is determined at the date of the decedent’s
death and if a person shown to be entitled then dies, payment is made to that person’s estate and all persons entitled must join in the application.
Denominational exchange, partial payment, or reissue in the names of survivors is not permitted.
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.

Provide the serial number and face amount of each unpaid bond or check.

ITEM 2.

Enter the full name of the deceased bond owner and/or payee of check. Enter the month, day, and year of death. Enter the decedent’s
complete legal residence at time of death. Mark the appropriate box to indicate the decedent's marital status at the time of death. (See
description of divorce in Item 3 below.) Provide the decedent's death certificate or a photocopy thereof.

ITEM 3.

Mark one box for each question, to indicate whether there were survivors of each class. Survivors are defined in detail below:
•
Surviving Spouse and/or Children - Wife or husband of owner or payee. A “child” includes: legitimate child, child legally adopted,
stepchild, if at the time of the decedent’s death such stepchild was a member of the decedent’s household; illegitimate child, but in
case of a deceased male, only if he has been judicially ordered or decreed to contribute to such child’s support, has been judicially
decreed to be the adopted father of such child, or has acknowledged under oath in writing that he is the father of such child; and a
person to whom the decedent at the time of his/her death stood loco parentis (designated caregiver) and so stood for not less than 12
months prior to his/her death.

ITEM 4.

•

Parents - Father or mother, grandfather or grandmother, stepfather or stepmother, father or mother through adoption, or any person
who stood in loco parentis (designated caregiver) to the deceased owner or payee for a period of not less than 12 months prior to the
death of the decedent. Preference will be given to the parent or parents, not exceeding two, who actually exercised parental
relationship at the time of or most nearly prior to date of death.

•

Brothers and Sisters - Brothers and sisters of whole blood, brothers and sisters of half blood, stepbrothers and stepsisters, and
brothers and sisters through adoption.

•

Children of Deceased Brothers and Sisters - Nieces and nephews of deceased owner or payee. See “Surviving Spouse and/or
Children” for definition of “child."

Enter the requested information, as indicated below:
•
Persons Still Living - Enter the full name of each person now living as defined in Instruction 3. For each person, furnish the
complete address, month, day, and year of birth, and exact relationship of the person to the decedent. In case of an application by a
parent other than the actual father and mother still living together, a signed and sworn statement must be attached giving the names
of all parents as defined in the Act, and stating facts relied upon to support the application submitted.
•

Persons Who were Living when the Decedent Died but Who have since Died - For each deceased person, enter date of death,
age of person at date of death, state whether married, single, or divorced, and show the relationship of each person to the deceased
owner.

ITEM 5.

Show the name of any person listed in Item 4 who is under legal disability. Under “Legal Disability,” enter the nature of the disability, such
as the individual is a "minor" or the individual is "incompetent." Under “Capacity” enter the official title or description of the representative,
for example, “legal guardian” or “conservator,” and show that person’s address. If appointed by the court, attach up-to-date proof of
appointment under court seal.

ITEM 6.

If applicant does not come under any category shown in questions 3 through 5, but is submitting application on behalf of one or more
survivors of the deceased owner or payee as a representative of the estate of any such survivor, or is acting in some similar representative
capacity, such applicant should give all necessary information relative to the deceased owner or payee and relative to the survivor on
whose behalf representation is made. Enter the full name and address of the applicant. Enter the full name of the survivor on whose
behalf application is made. Give the relationship of the applicant to the survivor, such as administrator, or executor of estate of deceased
child of deceased owner or payee. Explain fully the basis of application. Payment to minors will be made to a legally appointed guardian,
if one has been appointed (provide proof of appointment, under seal of the court). Otherwise, payment will be made as the Secretary of
the Treasury deems appropriate. The Secretary’s determination is final.

SIGNATURES – Each person entitled to payment in his/her own right or on behalf of a minor under age 17 or under a legal disability must sign the form
in ink, in the presence of an authorized certifying officer, and provide his/her daytime telephone number. A married woman, in signing, must use her
own given name, not that of her husband, as “Ms. Mary Jones,” not “Mrs. Frank Jones.” An IRS Form W-9 must also be completed and signed by
each survivor or his/her authorized representative, to certify the Social Security Number of that survivor.
CERTIFICATION – Each applicant must appear before and establish identification to the satisfaction of an authorized certifying officer and sign the form
in the presence of the officer. The certifying officer must complete the certification forms provided and affix the seal or stamp which is used when
certifying requests for payment. Authorized certifying officers are available at financial institutions, including credit unions, in the United States. For a
complete list of such officers see Department of the Treasury Circular No. 300, current revision, 31 CFR 306.
WHERE TO SEND – Send the completed FS Form 2066, the bonds and/or check, certified death certificate, and IRS Form(s) W-9 to Treasury Retail
Securities Site, PO Box 9150, Minneapolis, MN 55480-9150.
QUESTIONS? – Call us at 844-284-2676 (toll free).

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FS Form 2066