Form FS 1133 FS 1133 Claim Against the United States for the Proceeds of a Go

PAYEE INSTRUCTIONS
FOR COMPLETING CLAIM FORM FS 1133, CLAIM AGAINST THE UNITED
STATES FOR THE PROCEEDS OF A U.S. TREASURY CHECK.

PLEASE READ AND FOLLOW THE INSTRUCTIONS
1. The check you asked about has been cashed. The Treasury’s Check Claims is responsible for handling claims involving U.S.
Treasury checks.
2. Review the attached check copy, especially the handwritten and/or stamped endorsements.
3. Pay particular attention to the date of the check. If the check is not the one you are missing, or if you have a question

about the check amount, contact the federal agency which approved the payment giving them enough information to
locate the check in question.
4. If the check copy shows that the check was deposited at your financial organization, take the check copy to the bank or

credit union and ask them to verify that your account was credited. If you are unable to settle this matter, complete and
return the Claim Form (Pages 2 and 3) and check copy.
5. If you signed the check or the check was cashed with your permission, or if for any reason you do not want to make a

claim for the amount of the check, do not return the Claim Form.
6. Answer all questions on both pages. Signatures are required for Parts 1 and 2 since this form is sent to two separate

destinations for processing.
7. 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 check, then fill in BOTH PAGES (Pages 2 and 3) of the Claim Form. It is important that you:
A. ANSWER ALL QUESTIONS ON BOTH PAGES (items 1 through 8 on page 2) (items 9 through 16 on page

3). Please fill out the Claim Form in black ink.
B. Sign your name where indicated. If the check is issued to two payees, both payees must sign the Claim Form.
C. The signature of a Witness is required only when one or both payees sign their names with a mark.
D. RETURN THE CHECK COPY, YOUR COMPLETED FS 1133 CLAIM FORM (PAGES 2 & 3) TO THE

FOLLOWING ADDRESS.

U.S. Department of the Treasury
Bureau of the Fiscal Service
Post Payment Division
PO Box 51318
Philadelphia, PA 19115-6318

FS 1133

PAYEE: RETAIN THIS PAGE FOR YOUR RECORDS.

Page 1

Check Symbol:

Check Serial #:

Part 1

CLAIM AGAINST THE UNITED STATES FOR THE

OMB No. 1530-0010

PROCEEDS OF A GOVERNMENT CHECK

Exp. 7/31/94

“Do Not Fold”.

Please refer to the Privacy Act Statement following this form, which you may keep for your records.
Check Symbol:

Check Serial #:

Check Amount:

Check Issue Date:

Issued by:

Name(s) on check:

Payee Name 1:

WARNING: Title 18, Sec. 287, U.S. Code: “Whoever makes or presents to any person or officer in the civil, military, or naval service, of the United States, or to any department or agency thereof,
any claim upon or against the United States, or to any department or agency thereof, knowing such claim to be false, fictitious, or fraudulent, shall be fined not more than $10,000 or imprisoned not
more than five years, or both.”

1. Did you receive this check?
2. Did you sign your name on this check?
3. Did you cash this check?
4. Did you deposit this check in a bank, credit union or other
financial institution? Did someone else deposit this check in
an account you could use?
5. Was this check cashed with your permission?
6. Did you receive any money or benefit in any way from this
check (e.g. household expenses / child support etc.)? If so,
explain (include amount if known).
7. Is your present name different from that on the face of the
check? If so, explain why.
8. If you are making claim for this check and it is not made out
to you, state your relationship to the payee. Explain why the
payee cannot sign.
THIS CLAIM IS MADE FOR THE PROCEEDS OF THE ABOVE CHECK. IF YOU CASH BOTH ORIGINAL AND ANY SETTLEMENT CHECKS, THE OVERPAYMENT MUST BE PROMPTLY
REFUNDED. FAILURE TO DO SO COULD RESULT IN LEGAL ACTION. BE SURE TO INCLUDE THE ABOVE CHECK AND SYMBOL NUMBERS WITH YOUR REFUND.

SIGN

Payee’s Signature

2nd Payee’s Signature (if check drawn to two payees)

HERE
Your assigned I.D. No. (SSA, VA, IRS, Etc.)

2nd Payee’s assigned I.D. No. (SSA, VA, IRS, Etc.)

Signature of Witness (ONLY if payee(s) signed by mark)

FS 1133

Page 2

Check Symbol:

Check Serial #:

9. Did you ever live or receive mail at the address on the front of
this check?
10. What was your mailing address on the date this check was

Address

Apt.

issued? If you moved, did you advise the Post Office and
agency which authorizes the payment?

Zip
Yes

No

11. Did anyone other than yourself have the opportunity to receive
your mail? If so, who?
12. Did you lose any identification which might have been used by
someone else to cash your check? If so, explain.
13. Do you have information concerning the cashing of the check? If
so, explain. (Use additional paper if necessary.)
14. Where did you usually cash or deposit your check at the time
this check was cashed?
15.Clearly print your current mailing address.

Address

Apt.
Zip

16. If you are employed, give the name, address, and telephone
number of your current employer.

Name
Address

I CERTIFY THAT ALL THE ABOVE QUESTIONS HAVE BEEN ANSWERED
TRUTHFULLY TO THE BEST OF MY KNOWLEDGE.

SIGN
HERE

Phone Number

Give your current home address, telephone number and/or a number

Payee’s Signature

where you can be reached.
Date

Address

Zip

2nd Payee's Signature (if check drawn to two payees)
Telephone No. ( )
Date

Other No. ( )

To expedite the settlement of your claim, sign your name three (3) times below for handwriting comparison.
Payee’s Signature

2nd Payee’s Signature

1.

1.

2.

2.

3.

3.

Be sure to detach and retain the payee instruction page 1 for your records. If you move before your claim is settled, send your new address along
with the check and symbol numbers to the agency given on the instruction page, and advise the Post Office of your forwarding address.
COMPLETE BOTH PAGES OF THIS CLAIM FORM. You must return the check copy or we will be unable to process your claim.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The time
required to complete this information collection is estimated to average 10 minutes, including the time to review instructions, search existing data resources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Comments concerning the accuracy of the time estimate and suggestions for
reducing this burden should be directed to the Department of the Treasury, Bureau of the Fiscal Service, Parkersburg, WV 26106

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