SF 1055 Claims Against the U.S. for Amounts Due in Case of a Dec

OMB No. 1530-0004

Standard Form 1055
Rev. October 2015

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1. I/we, the undersigned, hereby make claim as
United States in the case of

who died on the

(Name of decedent)

of

for amounts due from the

(Relationship)

,

day

, while domiciled in the State of

2. The basis of this claim is as
(State nature of claim, amount, name and location of Department or Agency involved)

3. Has there been or will there be appointed an executor or administrator of the decedent's estate?
("Yes" or "No".) If the answer is "Yes," the following statement should be completed:
I/we have been duly appointed

(Executor or Administrator)

of the estate of the deceased, as evidenced

by certificate of appointment herewith, administration having been taken out in the interest of:
(Name, address, and relationship of interested relative or creditor)

and such appointment is still in full force and effect.
(If making claim as the executor or administrator of the estate of the deceased, no witnesses are required, but a
short certificate of letters testamentary or of administration must be submitted.) (If you are the executor or
administrator of the estate of the deceased, disregard paragraphs 4, 5, and 6.)
4. If an executor or administrator has not been or will not be appointed, the following information should be furnished:
The deceased is survived byName
Widow or widower (if none, so state):
Children (if none, so state):
Name

Age (if under 21)

Street Address, City, State, and ZIP Code

Grandchildren (list only the children of deceased children--if none, so state):
Name

Age (if under 21)

Street Address, City, State, and ZIP Code

Name of deceased
parent of grandchild

If no child or grandchild survives, enter below the following:
Name

Street Address, City, State, and ZIP Code

Father (if deceased, so state):
Mother (if deceased, so state):
Brothers and sisters (if none, so state):
Name

Age (if under 21)

Street Address, City, State, and ZIP Code

Nephews and nieces (list only the children of deceased brothers or sisters-if none, so state):
Name

Street Address, City, State, and ZIP Code

Age (if under 21)

5. Have the funeral expenses been paid?

Name of deceased parent
of nephew or niece

("Yes" or "No.") (If paid, receipted bill of the undertaker

must be attached hereto.)
6. Whose money was used to pay the funeral expenses?
(If funeral expenses were paid from the proceeds of an insurance policy, state the name of the beneficiary of
such policy.

)

FINES, PENALTIES, and FORFEITURES are imposed by law for making of false or fraudulent claims against the
United States or the making of false statements in connection therewith.

(Signature of claimant)

(Date)

(Signature of claimant)

(Street address)

(Street address)

(City, State, and ZIP code)

(City, State, and ZIP code)

(Date)

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We certify that we are well acquainted with the

(Name of claimant (s))

and that the signature(s) of the claimant(s) was (were) affixed in our
(Signature of witness)

(Signature of witness)

(Street address)

(Street address)

(City, State, and ZIP code)

(City, State, and ZIP code)

All unnegotiated Government checks in possession of the claimant, drawn to the order of the
decedent and involved in the claim, shall accompany this claim application.

INSTRUCTIONS FOR COMPLETING STANDARD FORM
1055
(Use additional paper if necessary)
1. (a)
Your relationship to the deceased
(b)
Name of the deceased
(c) Date when the deceased died
(d) Name of the State where deceased died
2. Completed by Treasury
3. (a)
the

If the estate has not been probated, put “no”, Complete #4, to end the form. If

estate has been probated in court put “yes”
(b) Insert whether Executor or Administrator only if estate is probated
(c) Name, address, relationship of interested relative or creditor. If the answer is
“yes”, a currently dated court certificate must be submitted showing your
appointment. If the estate has not been probated, the rest of the form must be
completed.
4. Widow or Widower
(a) If the deceased was married, put the name of the spouse and if not living put
“deceased” after the name and the date the person died. If never married, put
“never married”
Children
(b)
List the names of all children, both living and deceased. Put current addresses
after the names of the living children and put “deceased” after the names of
children who are deceased. If the deceased had no children, put “none”
Grandchildren
(c)
If any of the above children in (b) are deceased, place names and addresses of
the
children of those deceased children. Place the name of the deceased parent after
the name of the child. If the deceased child had no children of their own or never
married, so state.
Father & Mother
(d) If no spouse or children survived the deceased, put the names of deceased’s
Father and mother in proper place. If deceased, put “deceased” after names. If
Living put addresses after names.
Brothers & Sisters
(e) List the names of all brothers and sisters of the deceased, both living and
Deceased. Put addresses of the living brothers and sisters and put “deceased”
after the names of the deceased brothers and sisters.
Nephews & Nieces
(f) List names and addresses of the children of the deceased brothers and sisters
in (e) above.

5(a) If funeral expenses are paid, put “yes”. If not, put “no”
(b) If funeral expenses are paid, a copy of the paid funeral bill should be
submitted, showing who paid the bill. If the bill is not available,
a statement of explanation is required.
6. (a) The name of the person who paid the funeral bill.
(b) If any insurance money was used to pay the funeral bill, name of the
person who was the beneficiary of the insurance.
7. Signature of applicant, date and address
8. Signatures of two witnesses and their addresses.

BURDEN ESTIMATE STATEMENT

The estimate average burden associated with this collection is 8 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 shown in the instructions.