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FEDERAL RESERVE BANK
O F NEW YORK
Fiscal Agent of the United States

14
(Circular No. 319463 1J
October 16,

REGULATIONS GOVERNING THE INDORSEMENT AND
PAYMENT OF CHECKS DRAWN ON THE TREASURER
OF THE UNITED STATES

To all Banking Institutions in the
Second Federal Reserve D istrict:

There is enclosed a cop y o f T reasury D epartm ent Circu­
lar No. 21, R evised Septem ber 5, 1946, entitled “ Regulations
G overning the Indorsem ent and Paym ent o f Checks D rawn
on the T reasurer o f the U nited S t a t e s /’




A

llan

S

proul,

President.

UNITED STATES TREASURY DEPARTMENT

REGULATIONS
G O V E R N IN G THE

Indorsement and Payment of Checks
Drawn on the Treasurer of the
United States




D epartm ent Circular N o. 21
Revised September 5, 1946

16--- 49423-1

Regulations Governing the Indorsement and Payment of Checks Drawn on the Treasurer
of the United States
TABLE OF CONTENTS
Section
Page
1. D e f in it io n s ................ ............................................... ................... - .... ............................................. ..............................................
2. G u a r a n t y of I n d o r se m e n t s . . ...................................... ............... ..............- ------------------- ------------------------------------------3. F orm of I n d o r se m e n t _______ ________ __________________ ...................... ..................... .......................... ............................
(а) Individual payees— If b y attorneys in fact or legal representatives, see sections 4, 5, 6, and 7-------

3
3
3
3

(б) Indorsement by m ark______________________________________________________________________________________
(c) Corporations, governmental organizations (towns, cities, counties, districts, etc.), partnerships,
and other business firms___ . . ____________ ___________________ __________ ___________ ___________________
(d) Joint payees____ ____________ ________ ................................................................................................................. ............
(e) Alternate payees.................................................................... ................ .... ..........................................................................
(/) Attorneys in fact— See section 5......................................... ............ . ......... ............- ............... ...................................
(: ) Executors, administrators, guardians, receivers, trustees, etc.— See sections 4 and 6.............................
g
(h) Indorsement of checks for interest on or for principal of public debt obligations of the United
States, or obligations guaranteed by the United States______ _____ __________ ______ ____________ __
D ec e a se d Pa y e e s ___________ _____________ __ _____ ______________________ _______ _____ ____ ____ ___________ _____
(a) Classes of checks which m ay be indorsed by an executor or administrator_________ _________ _______
(b) Classes of checks which m ay not be indorsed b y an executor or administrator_______________________
C h e c k s I ndo r sed b y a n A t t o r n e y in F a c t ......... ................................................................ . ............... ....................—
I n c o m p e t e n t P a y e e s _____________________ _______ _________________ ___________ ____ ______ ________ ______ _____ _
M in o r P a y e e s . . ............................... ................................................... ............................... ......................... ..................................
(а) W hen minor m ay indorse______ ______________ ___________________________ ____ _____________________________
(б) W hen minor m ay not indorse........ ................................................................................. ......... ................. .....................
(c) W hen parent m ay indorse in behalf of minor_________________________ _______— ..........................................
C h a n g e of A d dr ess .............. ......... ......... ......... . ................. ........................ ...... ....... ........ ....................- .................................
L im ita tio n of T im e for P a y m e n t ....................... .............................................. ................................................................

5
5
5
5
6
6
6
6
7
7
7
7

10. G e n e r a l P r o v isio n s ___________________________ _____ _________________________ ______________________________»
.__

7

4.

5.
6.
7.

8.
9.




(2)

16 49423-1
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3
4
4
4
4
4

REGULATIONS GOVERNING THE INDORSEMENT AND PAYMENT OF CHECKS
DJIAWN ON THE TREASURER OF THE UNITED STATES
Department Circular No. 21
(Revised September 1946)
Fiscal Service
Office o f the Treasurer, U. S.

TREASURY DEPARTM ENT
O FFIC E O F T H E S E C R E TA R Y
W A S H IN G T O N , D. C ., S E P TE M B E R 5, 1946

To all Banks and Bankers and Others Concerned:
The indorsement of checks drawn on the Treasurer of the United States shall be
governed by the following regulations. The regulations herein contained governing the
indorsement o f checks by the payee shall also apply to and govern the indorsement of
checks by any person, firm, corporation, or association to which any check has been
specially indorsed.
1. Definitions.— The word “ check” or “ checks” shall be deemed to mean checks drawn
on the Treasurer of the United States ; the term “ presenting bank” shall be deemed to mean
( 1) a bank or depositor of a Federal Reserve Bank presenting a check to a Federal Reserve
Bank for payment and from which the Federal Reserve Bank is authorized by the pro­
visions of Treasury Department Circular No. 176 to receive such checks, or (2) a bank pre­
senting a check for payment direct to the Treasurer under special arrangements with the
Treasurer; and the word “ Treasurer” shall be deemed to mean the Treasurer of the United
States.
2. Guaranty of indorsements.— The presenting bank and the indorsers of a check
presented to the Treasurer for payment are deemed to guarantee to the Treasurer that all
prior indorsements are genuine including that of the drawer when the check is drawn in the
drawer’s favor, whether or not an express guaranty is placed on the check. When the first
indorsement has been made by one other than the payee personally, the presenting bank
and the indorsers are deemed to guarantee to the Treasurer, in addition to other warran­
ties, that the person who so indorsed had unqualified capacity and authority to indorse
the check in behalf of or in lieu of the payee.
3. Form of indorsement.— All indorsements should be in ink or indelible pencil. If
the name of the payee is misspelled on the check, he should indorse the check as drawn and
also in his correct name. If the name of the payee has been changed by marriage, or court
decree or order, the check should be indorsed in the name as it appears on the face thereof
and also in the present name. In case of a material deviation from the correct designation
of the payee, the check, accompanied by a statement as to the payee’s correct designation,
should be returned to the drawer without alteration, correction, or indorsement in order
that appropriate steps may be taken for authorization of payment to the party ascertained
to be entitled, or the issuance of a corrected check.
(a-) Individual payees.— All checks should be indorsed by the payee personally or by
his attorney in fact or legal representative. As to indorsements by attorneys in fact or
legal representatives, see sections 4, 5, 6, and 7.
( b)
Indorsement by mark.— Indorsement by mark (X ) should be witnessed by two
persons who must sign their names as witnesses and give their addresses in full, as :




4

His
John (X ) Doe,
Mark
Witness: James Smith,
1000 Columbia Road,
Doeville, N. Y.
Witness: Martha Jortes,
2121 9th Street,
Doeville, N. Y.

(c)
Corporations, Governmental organizations {towns, cities, counties, distric
etc.), partnerships, and other business firms.— Stamped indorsements of corporations,
governmental organizations (towns, cities, counties, districts, etc.), partnerships, and other
business firms used in due course of business are acceptable when the check is presented for
payment by a bank. When such checks are indorsed manually they should be indorsed in
the name of the payee by, as the case may be, a duly authorized officer over his official
title, a member of the firm in that capacity, or the individual as sole owner, a s:
1. Corporations:
X. Y. Z. Inc.
By James Smith, Treasurer.
2. Governmental Organizations:
X County, Maine,
By John Doe, Treasurer.

3. Partnerships:
Parker and Jones,
By John Jones, General Partner.
4. Sole Ownerships:
Doe’s Drug Store,
By John Doe, Sole Owner.

(id) Joint payees.— A check drawn to two or more payees jointly should be indorsed
by all of them; for example, a check drawn to James Smith and Elizabeth Jones should be
indorsed by each payee individually, as:
v
James Smith.
Elizabeth Jones.
(e)
Alternate payees.— A check drawn to two or more payees alternately may
indorsed by any one of the payees; for example, a check drawn to James Smith or Elizabeth
Jones may be indorsed by either of them, as:
Elizabeth Jones.
( / ) Attorneys in fact.— The indorsement should be in the name of the payee by the
attorney in fact with an indication of the capacity in which he indorses, a s:
Frank Smith,
By John Smith, Attorney in Fact.
Section 5 contains information as to the types of powers of attorney required for the
various classes of checks.
( g ) Executors, administrator's, guardians, receivers, trustees, etc.— In cases where
there has been appointed an executor, administrator, guardian, receiver, trustee, or other
fiduciary whose authority includes the indorsement of checks in behalf of the payee or his
estate, the check should be indorsed by such executor, administrator, guardian, receiver,
trustee, etc., as the case may be, a s:
Donald Clark,
By Sarah Jones, Executrix.
See also sections 4 and 6 for information as to classes of checks which are not payable after
the death or incompetency o f payees.




5

(h) Indorsement of checks for interest on or for principal of public debt obligations
of the United States, or obligations guaranteed by the United States.— When a check issued
in payment of interest on or principal of public debt obligations or of obligations fully and
unconditionally guaranteed both as to principal and interest by the United States, is
credited by a bank to the payee’s account under his authorization, it should be indorsed
in the following fo rm :
“ Credited to the account of the withinnamed payee in accordance with payee’s in­
structions. Absence of indorsement guaranteed.
XYZ Bank.”
A bank using this form of indorsement on these checks will be deemed to guarantee
to all subsequent indorsers and to the Treasurer that it is acting as an attorney in fact
for the payee under his authorization.
This form of indorsement may also be used on these classes of checks by trust com­
panies, savings and loan associations, and credit unions.
4.
Deceased payees.— (a) Checks issued for the following classes of payments, the
right to which does not terminate with the death of the payee, will when indorsed by an
executor or administrator be paid by the Treasurer without the submission to the Treas­
urer of documentary proof of the authority of the executor or administrator:
1. Principal or interest on public debt obligations or obligations
guaranteed by the United States.
2. Tax refunds.
3. Payments for goods and services.
If an executor or administrator has not been appointed, the person or persons claiming as
owner must return the check to the drawer or to the appropriate administrative office
which authorized its issuance, together with an executed Form 1055, which form is repro­
duced at the end of this circular and is made a part hereof. Form 1310, also reproduced
at the end of this circular and made a part hereof, may be used in lieu of Form 1055 for tax
refund checks.
( b)
Other classes of checks must not be negotiated after the death of the payee but
must be returned to the drawer or to the administrative office which authorized issuance
of the check for determination whether, under applicable laws, payment is due and to whom
it may be made. Examples of these classes of checks are as follow s:
1. Allotments.
2. Annuities.
3. Civil Service refunds.
4. Compensation, excepting salary, pay, etc.
5. Dependency (family) allowances.
6. Educational subsistence payments.
7. Insurance.
8. Mustering-out payments.
9. Pensions.
10. Retirement (Army, Navy, Marine Corps, and Coast Guard; District of Colum­
bia Teachers’ Retirement, and Policemen’s and Firemen’s R elief).
11. Social Security benefits.
12. Unemployment readjustment allowances.
13. Armed Forces Leave Act of 1946.




6

5. Checks indorsed by an attorney in fact.— Checks indorsed by an attorney in fact
for the payee and presented for payment by a bank will be paid by the Treasurer without
the submission to the Treasurer of documentary proof of the authority of the attorney in
fact. Attention of banking institutions and others concerned is called to the fact that a
specific power of attorney, executed after the issuance of the check, describing the check
in full, is required for the following classes of checks:
1. Compensation, excepting salary, pay, etc.
2. Dependency (family) allowances.
3. Educational subsistence payments.
«
4. Mustering-out payments.
5. Pensions.
6. Unemployment readjustment allowances.
7. Settlement warrants.
8. Armed Forces Leave Act of 1946.
9. Allotments.
*
10. Annuities.
11. Social Security benefits.
12. Insurance.
13. District of Columbia Teachers’ Retirement, and Policemen’s and Firemen’s
Relief.
However, for classes 9 to 13, inclusive, a special power of attorney naming a bank as attor­
ney in fact, limited to a period not to exceed 12 months and reciting that it is not given to
carry into effect an assignment of the right to receive the payment, either to the attorney in
fact or to any other person, may also be used. Forms of powers of attorney are reproduced
at the end of this circular and are made a part hereof, together with identification of and
descriptive information as to the classes of checks which may be negotiated under the
various powers. Substantial compliance with these forms is sufficient. Powers of attor­
ney are revoked by the death o f the grantor and may also be revoked by notice from the
grantor to the parties concerned. Notice of revocation to the Treasury will not ordinarily
serve to revoke the power.
6. Incompetent payees.— Where the payee of a check of the classes listed in paragraph
(b) of section 4 and others not covered in paragraph ( a) of section 4 has been declared
incompetent, the check should not be indorsed by a guardian or other fiduciary but, instead,
should be returned to the drawer, or to the administrative office which authorized the issu­
ance of the check, with information as to the incompetency of the payee and submission of
documentary evidence showing the appointment of the guardian, in order that the partic­
ular check, and others to be issued subsequently, may be drawn in favor of the guardian. If
a guardian has not been and will not be appointed the full circumstances should be stated.
Checks of the classes listed in paragraph (a) of section 4 indorsed by a guardian or
other fiduciary and presented for payment by a bank will be paid by the Treasurer without
the submission to the Treasurer of documentary proof of the authority of the guardian or
other fiduciary. If a guardian has not been and will not be appointed, the check should be
forwarded for advice to the Treasurer of the United States, Accounting Division, Wash­
ington 25, D. C.
7. Minor payees:
(a)
Where the payee o f a check is a minor, his indorsement is acceptable provided t
minor is of sufficient age and competency to understand the act of indorsing and giving
receipt.




7

( b) Otherwise, the check should be indorsed by a duly authorized legal representative
of the payee’s estate or if none has been appointed the check should be returned to the
drawer with a view to issuance of a check in the name of the person qualified to act for the
minor.
(c)
However, checks in payment of interest on or principal of public debt obligations
or obligations guaranteed by the United States may be indorsed by either parent with
whom the minor resides, or, if the minor does not reside with either parent, by the person
who furnishes his chief support. In the cases covered by the preceding sentence a state­
ment should be obtained from the parent or other person indorsing in behalf of the minor,
giving the minor’s age and setting out the fact that the payee either resides with the
parent or receives his chief support from the person indorsing in his behalf and that the
proceeds of the check will be used for the benefit o f the minor, which statement should
accompany the check.
8. Change of address.— Every person receiving checks periodically should see that the
appropriate administrative office is informed of his correct address, as failure so to notify
the administrative office may result in delivery of a check to a wrong address. If doubt
exists as to the office to be notified, the change of address should be sent to the drawer of
the checks, with information as to the purpose for which the checks are issued. The request
for change of address should always describe the character of the checks received, give the
name and former address of the payee, the new address, and the payee’s identification
number, if one has been assigned. The request should be signed by the payee of the checks.
9. Limitation of time for payment:
(a)
After the expiration of one year following the close of the fiscal year (ending
June 30) in which they are drawn, checks drawn on the Treasurer of the United States
(including checks payable through designated Federal Reserve banks) are not payable by
him but should be transmitted to the Secretary of the Treasury, Division of Disbursement,
for payment from the “ Outstanding Liabilities” appropriation, accompanied by a request
for payment over the signature and address o f the owner of such checks :
( b) Provided, however, That the one-year restriction does not apply to checks issued
on account of public debt obligations and checks issued on account of transactions regard­
ing the administration of banking and currency laws.
10. General Provisions.— The provisions of Department Circular No. 21 of October
28, 1913, are hereby superseded. Further regulations concerning the payment of checks
by the Treasurer are contained in Treasury Department Circular No. 176, section 25 of
which prescribes the procedure for handling o f checks by Federal Reserve banks. The
Secretary o f the Treasury may waive, withdraw, or amend at any time or from time to
time any or all o f the provisions of this Circular.
J o h n W. S n y d e r ,
Secretary of the Treasury.
TREASURY DEPARTMENT FORMS FOR POWER OF ATTORNEY AND THEIR
APPLICATION
None of the various types of checks issued by the Government are assignable and
many represent classes of payments the right to which ceases with the death of the payee.
In order to give effect to the laws under which the payments are made it has been neces­
sary to require that checks representing certain classes o f payments be indorsed by the
payee personally or that they be indorsed under authority evidenced by special types of
powers of attorney, prescribed by the Treasury Department.




8

Form 6569.— A general power of attorney on this form may be executed by an individual,
firm or sole owner, for all checks .drawn on the Treasurer of the United States, with
the exception of the following classes:
1. Compensation, excepting salary, pay, etc.
•
2. Dependency (family) allowances.
3. Educational subsistence payments.
4. Mustering-out payments.
5. Pensions.
6. Unemployment readjustment allowances.
7. Settlement warrants.
8. Armed Forces Leave Act of 1946.
9. Allotments.
10. Annuities.
11. Social Security benefits.
12. Insurance.
13. District of Columbia Teachers’ Retirement, and Policemen’s and Firemen’s
Relief.
F o r m 6570.— A specific power of attorney on this form, which must be executed after the
issuance of the check, describing the check in full, is required for classes 1 to 13, inclu­
sive, of those checks listed above: Provided, however, That for classes 9 to 13,
inclusive, Form 6711 may be used subject to the conditions set forth below.
F o r m 6571-2.— A g e n e ra l p o w e r o f a tto r n e y on th is fo r m m a y b e ex ecu ted b y a c o r p o r a ­
tio n u n d e r th e sa m e c o n d itio n s as p r e s c r ib e d f o r F o r m 6569.
F o r m 6573-4.— A specific power of attorney on this form is required by a corporation for
checks drawn by the Treasurer of the United States in payment of settlement
warrants.
F orm 6711.— A special power of attorney on this form naming a bank as attorney in fact,
limited to a period not to exceed 12 months and reciting that it is not given to carry
into effect an assignment of the right to receive the payment, either to the attorney in
fact or to any other person, may be used for classes 9 to 13, inclusive, of those checks
listed above.
F o r m P. D. 1036.— A power of attorney on this form-may be used for checks in payment
of interest on or principal of securities registered on the books of the Treasury
Department. (Form 6569 may also be used for this purpose.)
F o r m P. D. 1036A.— This form is intended for the use of one or more of several trustees
to empower one of the co-trustees to indorse checks in payment of interest on or prin­
cipal of securities registered on the books of the Treasury Department.
F o r m P. D. 1037-42.— T h is fo r m is in te n d e d f o r use b y a c o r p o r a tio n u n d e r th e sa m e
co n d itio n s as p r e s c r ib e d f o r F o r m 1036.
(F o r m 6571-2 m a y a lso be u sed .)
N o t e .— A general power need not be reexecuted for the collection of subsequent checks
under the same power. Powers of attorney are revoked by the death of the grantor
and may also be revoked by notice from the grantor to the parties concerned. Notice
of revocation to the Treasury will not ordinarily serve to revoke the power.
CLAIM FORMS FOR USE WHEN PAYEE IS DECEASED
1055.— This form may be used in filing claim with the General Accounting Office,
Washington, D. C., for the amounts o f checks of classes referred to in section 4 (a)
hereof, in cases where an executor or administrator is not acting.
FORM 1310.— T h is fo r m m a y b e u sed in ste a d o f F o r m 1055 i f th e ch e ck re p re s e n ts a ta x
F orm

r e fu n d .




.„ -« « a .,

F o r m 6569
T R E A S U R Y D E PA RTM EN T
U. S.— A c c o u n t i n g D i v i s i o n

(Note.— The grantor's Christian name, additional initials, if any, and surname should be used in the execution
o f the power of attorney.)

T reasu rer,

(Revised)

POWER OF ATTORNEY BY INDIVIDUAL FOR THE COLLECTION OF CHECKS DRAWN ON
THE TREASURER OF THE UNITED STATES

Know all tiàtn by tljese Presents:
That the undersigned,..... _______ ______________________________ __ __________________________ , of
____ ____ __________ _____________________________ __ ______ ___ , does hereby appoint__________________
(Post-office address)

--------------------------------------------------------------------- , Of

--------------------------------------- -------- --------------------(Post-office address)

as his attorney to receive, indorse, and collect checks payable to the order of the undersigned, drawn on the
Treasurer of the United States, for whatever account, and to execute in the name and on behalf of the
undersigned, all bonds, indemnities, applications, or other documents, which may be required by law or
regulation to secure the issuance of substitutes for such checks, and to give full discharge for same, grant­
ing to said attorney full power of substitution and revocation, hereby ratifying and confirming all that
said attorney, or his substitute, shall iawfully do or cause to be done by virtue hereof.
W

it n e s s

the signature and seal of the undersigned, th is_____________________________________ day

o f ---------- ------------------------------------------------- , 19____
______________________________________________________ [ s e a l ]
(Signature of grantor)

Personally appeared before me the above-named___ ____ _____________________ ___ ___ _______ J
______
known or proved to me to be the same person who executed the foregoing instrument, and acknowledged
to me that he executed the same as his free act and deed.
W ITN ESS

my signature, official designation, and seal.

(Signature o f attesting officer)

[IMPRESS SEAL HERE]

(Official designation)

Dated a t _________________ , t h is ____________________ day o f _____________________________ , 19.
My commission expires________________________________________ , 19,
IMPORTANT.— Do not execute this instrument without first reading the instructions on the reverse side hereof.
compliance with these instructions will avoid complications.




Exact

16 ----- 4 9 4 2 3 - \

F o r m «5 7 0
TEBA8U BY DEPARTM EN T
T u a s c b x s U. 8.

POW ER OF A T T O R N E Y B Y IN D IV ID U A L FOR TH E COLLECTION OF A SPECIFIED
CH ECK D R A W N ON TH E TR EASU R ER OF TH E U N ITE D STATES

SCnoui a ll ¿Ken b y th e s e p r e s e n t s :
That the undersigned,..................................................................................................................................... , of
....... .................................................................................... , does hereby appoint.....................................................
(Post-office address)
.............................................................................................. t

o f ......................................

(Post-office address)

as attorney to receive, indorse, and collect check N o .....................dated................................................, 19.
for „1...................................................................................................................................................................dollars
drawn on the Treasurer of the United States, by................................... ..................................................................
Symbol N o........................................ , in favor o f ...................................... .......................... ...................... , and to
give full discharge for same; hereby ratifying and confirming all that said attorney shall lawfully do or cause
to be done by virtue hereof.
W it n e s s

the signature and seal of the undersigned, this.....................................................................day of

- ..........................................................................................,

19..........
..........................................................................................................................[ s e a l ]

(Address)

Two witnesses

(Address)

Personally appeared before me the above-named....................................................................................... ......
known or proved to me to be the same person who executed the foregoing instrument, and acknowledged to
me that he executed the same as his free act and deed ; and I hereby certify that the said power of attorney
was read and fully explained to the said grantor at the time of acknowledgment.
W it n e s s

my signature, official designation, and seal.

(Signature of attesting officer)
[im p r e s s

seal

here

]

(Official designation)

Dated at................................................. , this.......... .............day o f ....................................................... 19
My commission expires ..............................................} 19
IMPORTANT.— Do not execute this Instrument without first reading the instructions on the reverse side hereof.

compliance with
i6—« « 3 .,
http://fraser.stlouisfed.org/ these instructions will avoid complications.
Federal Reserve Bank of St. Louis

Exact

F o r m 6571
TREASU RY D E PA RT M E N T
T r e a s u r e r , U. S.

P O W E R OF A T T O R N E Y B Y A C O R P O R A T IO N FO R T H E CO LLE C TIO N OF CH E CK S
D R A W N ON T H E T R E A S U R E R OF T H E U N IT E D STATES

2&noto alï ffitu fop tfjege $ r e 2ienté:
T h a t................ __________________________________ _____________ _________________ , a corporation
(Exact name o f corporation)

duly organized and existing under and by virtue of the laws o f ................... ............................................,
with its principal office a t ------------------- !------------------------------------------------------------ --------------------------- ,
_
does hereby a p p o in t_______ ...__ _ _____________________________________ , whose post-office address
i s _____________________________________________________________ _ as attorney to receive, indorse, and
collect checks in its name fo r whatever account, drawn on the Treasurer o f the United States, and to
give full discharge fo r same.
The said corporation hereby ratifies and confirms all that may lawfully be done by virtue hereof.
IN W i t n e s s W h e r e o f said corporation has caused this instrument to be executed in its behalf,

pursuant to authority o f its Board o f Directors, by its _______ _____________________ ___________ ___ ,
(Official title of officer)

and its corporate seal to be hereunto attached, attested by its secretary or assistant secretary, this
______ day o f ...................... - ---- -------------- , 19-......
[ im p r e s s s e a l h e r e ]

_____ ___________________________________ ________________ ,
(Name of corporation)

Attest:

B y ..... ............... ............................................ ................. .......
(Official signature o f officer)

Secretary .

(Official title of officer)

Personally appeared before me the above-named ____________________________________________ ,
known or proved to me to be the same person who executed the foregoing instrument and to be the

(Title of officer)

(Name o f corporation)

and acknowledged to me that he executed the same as his free act and deed and the free act and deed
o f said corporation.
W it n e s s

my signature, official designation, and seal.

[IMPRESS SEAL HERE]

(Signature of attesting officer)

(Official designation)

Dated a t _____________________ _____ __, t h is _________ day o f __________________________ 19-----My commission exp ires______________ ,______ , 19____
DigitizedIMPORTANT.— Do not execute this instrument without first reading the instructions on the reverse side hereof.
for FRASER
Exact compliance with these instructions will avoid complications.


F o r m 6572
TR E A SU R Y D E P A R T M E N T
T r e a s u r e r , U. S.

RESOLUTION B Y CORPORATION CONFERRING AUTHORITY UPON AN OFFICER TO
EXECUTE A POWER OF ATTORNEY FOR THE COLLECTION OF CHECKS
DRAWN ON THE TREASURER OF THE UNITED STATES

R e s o l v e d , T h a t __________ ___ _____ ___________________________________ _____ ______ , does hereby
(E x a ct corporate nam e)

name ________________ __ ____._ __________ _ , as attorney, with power o f substitution, to receive,
_
_
(N am e o f attorn ey)

indorse, and collect fo r and in behalf o f the corporation any check drawn on the Treasurer o f
the United States fo r whatever account and to give full discharge therefor; and further, that
____________________________________ _____ ___ be, and is hereby authorized and empowered to execute,
(N am e and title o f officer)

in behalf o f said corporation, a power o f attorney appointing the s a id ........
(N am e o f attorney)

as such attorney fo r the purpose above expressed.
The said corporation hereby ratifies and confirms all-that may lawfully be done by virtue hereof.
I h e r e b y c e r t i f y that the foregoing is a true and correct copy o f a resolution passed at a

meeting o f the Board o f ...._____________ ____ ________, the governing body
(R egu la r o r special)

o f ____________ __________________________ —___ _____ ____ ________, a corporation duly organized and
(Exact corporate name)

existing under and by virtue o f the laws o f .............................................., held on the ................. ....... day
o f ............. —............. —................ , 19........ , a t ............. ....................... ...........................................
A n d I f u r t h e r c e r t i f y that due notice o f said meeting was given to each member o f said
B oa rd ; that a quorum was present; and that said resolution has not been amended or repealed.
W i t n e s s m y signature and the seal o f said corporation, t h i s ______________________________ day

o f ............ ...............- .....-........., 19____

[ im p r e s s c o r p o r a t e s e a l h e r e ]

__________ ________ .._____ ...__________
(O fficial signature o f officer)

(Official title o f officer)

IM PORTANT.— Do not execute this instrument without first reading the instructions on the reverse side hereof.
Exact compliance with these instructions will avoid complications •
16 49423-1
----




F o r n i 6673
TREASURY DEPARTMENT
T r e a s u r e r U. S.

POW ER OF A T T O R N E Y B Y A CO RPO RATIO N FOR TH E COLLECTION OF A SPECIFIED
C H E C K D R A W N ON T H E TR E A SU R ER OF TH E U N ITED STATES

2Cttoui a ll ffiztt b y tlyese P r e s e n ts :
T hat........ ................................................................ ........................................................... , a corporation
( Exact name o f corporation)

duly organized and existing under and by virtue o f the laws o f .............................................................. .
with its principal office at .i................................. .................................................... .......................-................,
does hereby appoint____________ ____ ________________ _______________ , whose post-office address
i s ..............................................................................................., as attorney to receive, indorse, and collect
check N o ............................................., dated ................................................. ...................................., 19___
for ...... ...................................................................................................... - ............................ ..............dollars
drawn on the Treasurer of the United States, b y ... ...................................... ...................... ..... ..................
symbol N o ._________________ , in favor o f .......................
and to give full discharge for same.
The said corporation hereby ratifies and confirms all that may lawfully be done by virtue hereof
I n W i t n e s s W h e r e o f said corporation has caused this instrument to be executed in its behalf
pursuant to authority of its Board of Directors, by it s ___ ______________ ___________
_
(Official title o f officer)

and its corporate seal to be hereunto attached, attested by its secretary or assistant secretary
th is........................day of —___ ___ ____________________ , 19____
_
[ im p r e s s s e a l h e r e ]

............. ...........................
(Nam e o f corporation)

Attest :

B y __________
(Official signature o f officer)

Secretary.

Two
I
witnesses \

(Official title o f offiecr)

(N am e)

(Address)

(N am e)

(Address)

Personally appeared before me the above-named................................... ...........................................
known or proved to me to be the same person who executed the foregoing instrument and to be the

( Title o f officer)

( Name o f corporation )

and acknowledged to me that he executed the same as his free act and deed and the free act and deed
o f said corporation.
W it n e s s my signature, official designation, and seal.
[IMPRESS SEAL HERE]

(Signature o f attesting officer)

(Official designation)

Dated a t.......................................................... , this___________ day o f .... ................................, 19____
My commission expires__________________________ __, 19____
IMPORTANT.— Do not execute this instrument without first reading the instructions on the reverse side hereof.

 with these instructions will avoid complications.
Exact compliance


l€ f — 4 9 4 2 3 * 1

F o r m 6 57 4
TREASU RY DEPARTM ENT
T r e a s u r e r U . S.

RESOLUTION B Y CORPORATION CONFERRING AUTHORITY UPON AN OFFICER TO
EXECUTE A POWER OF ATTORNEY FOR THE COLLECTION OF CHECKS
DRAWN ON TftE TREASURER OF THE UNITED STATES

Resolved, T h at__________________________________________________________ ______ does hereby
(E x a c t corporate nam e)

_
n am e__________ ___ _____ _____ _ ___________, as attorney, to receive, indorse, and collect fo r and in
(N am e o f attorn ey)

behalf o f the corporation any check drawn on the Treasurer o f the United States fo r whatever account
and to give full discharge th erefor; and further, th a t....... ............ ..................................................................
(N am e and tiUe o f officer)

be, and is hereby authorized and empowered to execute, in behalf o f said corporation, a power o f
attorney appointing the s a id _______ ________ _____________________ , as such attorney fo r the purpose
(N a m e o f attorn ey)

above expressed.
The said corporation hereby ratifies and confirms all that may lawfully be done by virtue hereof.
I

hereby certify

that the foregoin g is a true and correct copy o f a resolution passed at a

-------------------------------------- meeting o f the Board o f ______ ___ _____ ____ _____ ____, the governing body
(R egu la r or special)

o f ______ ___ ____________________________ a corporation duly organized and existing under and by
(E x a ct corporate nam e)

_
_
_
virtue o f the laws o f _____________ _ ..____ ________ _ ______ _____, held on th e _____ ________day o f

.......... ............................................ , 19____ , a t ................... ......................... ................ ..............................................
A nd I

further certify

that due notice o f said meeting was given to each member o f said B oard;

that a quorum was present; and that said resolution has not been amended or repealed.
W itness m y signature and the seal o f said corporation, th is .............................. ........................ day
o f ___ _______ ___________________ , 19____

[IMPRESS CORPORATE SEAL HERE]

_______ _____________________ ____________
(Official signature o f officer)

(O fficial title o f officer)

IMPORTANT.— Do not execute this instrument without first reading the instructions on the reverse side hereof.


Exact compliance with these instructions will avoid complications.


16 49423-1
----

(N ote.— The grantor's Christian name, additional
initial«, if any, and surname should be used in the
execution o f the power o f attorney.)

F o r m 6711

TREASURY DEPARTM ENT
TMAsmutB’s O rn cï—a c c o u n t i n g d i v i s i o n

POWER OF ATTORNEY BY INDIVIDUAL TO A BANK FOR THE COLLECTION OF CHECKS DRAWN ON THE
TREASURER OF THE UNITED STATES

K n ow A ll M en

by

T h ese P r e s e n t s :

----------------------------------------------, o f

That the undersigned,___________

___________ , does hereby appoint
(Post-office address)

(A responsible banking institution or trust company must be named)

o f ___________________________________ ____________________________ , as his attorney to receive, indorse,
(Post-office address)

and collect checks payable to the order o f the undersigned, drawn on the Treasurer o f the United States
(State purpose for which checks are issued)

dated fr o m __________________________ , 19____ , t o _______ . .____ _____________ , 19__and to give full
r
(Time not to exceed 12 months)

discharge for same, hereby ratifying and confirming all that said attorney shall lawfully do by virtue
hereof. This power of attorney is not given to carry into effect an assignment to the attorney, or to any
other person, of the right of the undersigned to receive the above-described payments.
W it n e s s the signature and seal of the undersigned, th is ________ day o f __________________ , 19____

(Signature of grantor)

Personally appeared before me the above-named------------------------------------------ --------------------------------known or proved to me to be the same person who executed the foregoing instrument, and acknowledged
to me that he executed the same as his free act and deed.
W it n e s s my signature, official designation, and seal.

(Signature o f attesting officer)

[ im pr e ss

seal h e r e ]

(Official designation)

Dated at

-------------------------

-, t h i s ---------- -- ----------- day o f ___.____________________ , 19.

M y commission ex p ires______ »_____________19_____ _
I mportant.— Do not execute this instrument without first reading the instructions on the reverse side hereof. Exact
compliance with
ie— m23. i
*
these instructions will avoid complications,


F o r m P D 1036

TREASURY DEPARTMENT
'
T r e a s u r e r , U. S.
(Rev. Dec. 1941)

POWER OF ATTORNEY BY INDIVIDUAL FOR THE COLLECTION OF CHECKS FOR
INTEREST ON OR PRINCIPAL OF SECURITIES REGISTERED ON BOOKS OF TREAS­
URY DEPARTMENT

2Cnaui all Men by ttfeae Presents:
That the undersigned,________________________________________________________________________, of

----------------------------------------------------------------------------------- -------------------------------------- , does hereby appoint
(Post-office address)

---------------------------------------------------- -------------------------------------, O f ---------------------------------------------------- ...------ ---------------------- ,
(Post-office address)

as my attorney, for me and in my name and stead, to receive, receipt for, indorse, and collect checks,
whether for interest on or principal of any and all United States securities and other securities with
respect to which the Treasury Department acts as the transfer agency, now registered or heretofore
or hereafter registered in the name of the undersigned, and to give full discharge therefor, granting to
said attorney full power to appoint one or more substitutes for the purposes herein expressed.
The undersigned hereby ratifies and confirms all that may lawfully be done by virtue hereof.
W it n e s s the signature and seal of the undersigned, th is ___________day o f _________________ , 19_____

[ seal]

Personally appeared before me the above-named__________________________________________________ ,
known or proved to me to be the same person who executed the foregoing instrument, and acknowledged
to me that he executed the same as his free act and deed.
W it n e s s my signature, official designation, and seal.

(Signature of attesting officer)

[IMPRESS SEAL HERE]

(Official designation)

Dated a t ________________ :------------------ l— , th is---------------- day o f ________________________, 19
My commission expires-------------------------------------------------, 19____
IM PO R TAN T.— Do not execute this instrument without first reading the instructions on the reverse side hereof.
compliance with these instructions will avoid complications.




Exact

F o r m P . D . 1036-A
TREASURY DEPARTMENT
T b e a s u r e b , U. S.

POWER OF ATTORNEY BY INDIVIDUAL TRUSTEE FOR THE COLLECTION OF CHECKS FOR
INTEREST ON OR PRINCIPAL OF SECURITIES REGISTERED
ON BOOKS OF TREASURY

ftttaui all ¿ttfett by

Presents:

That the undersigned
whose address i s ________
under__ _________________

.. one of the trustees
(Here describe trust sufficiently for easy identification)

does hereby appoint________________________________________ ________________________ _____ __________
a cotrustee o f said trust, whose address i s ____________________________________________________________
as my attorney, for me and in my name and stead as such trustee, to receive, receipt for, indorse, and col­
lect checks, whether for interest on, or principal of, any and all bonds now or hereafter registered in the
names o f the trustees o f said trust on the books o f the Treasury Department, or for which the Treasury
Department acts as transfer agency, and to give full discharge therefor, granting to said attorney full
power to appoint one or more substitutes fo r the purposes herein expressed.
The undersigned hereby ratifies and confirms all that may lawfully be done by virtue hereof.
W it n e s s the signature and seal o f the undersigned, th is_______ __ day o f _________ ____ ________ ,
_

19___
____________ _____...__ ___ ____________________________ [ s e a l ]

Personally appeared before me the above-named_____________ ___________ __
known or proved to me to be the same person who executed the foregoing instrument, and acknowledged
to me that he
executed the same as his
free act and deed.
W it n e s s m y signature, official designation, and seal.

(Signature of attesting officer)

[ im p r e s s

seal here]
(Official designation)

Dated a t ...................................................., this .................. day o f ___ __ _____ _________________ , 19.
_
My commission expires_______ ________ _________ , 19

IM PORTAN T.— Do not execute this instrument without first reading the instructions on the reverse side hereof.




16----- 4 0 4 2 3 -1

F o r m P .O . 1037
TREASURY DEPARTMENT
T r e a s u r e r , U. S.
(Revised Dec. 1941)

POWER OF ATTORNEY BY CORPORATION FOR THE COLLECTION OF CHECKS FOR
INTEREST ON OR PRINCIPAL OF SECURITIES REGISTERED
ON BOOKS OF TREASURY DEPARTMENT

2Crtmu

all Men fay tl}ese JJresettts:

T h a t..._______________________________________________________________________ , a corporation
(Exact name of corporation)

duly organized and existing under and by virtue o f the laws o f _______________________ _________
with its principal office a t ---------------------------------------------------------------------------------------------------------does herfeby appoint...................................... ......................... ........................... , whose post-office address
is ____________________________________________________________, as attorney to receive, receipt for,
indorse, and collect checks, whether for interest on, or principal of, any and all United States
securities and other securities with respect to which the Treasury Department acts as the trans­
fer agency, now registered or heretofore or hereafter registered, in the name of said corporation,
and to give full discharge therefor, granting to said attorney full power to appoint one or more
substitutes for the purposes herein expressed.
The said corporation hereby ratifies and confirms all that may lawfully be done by virtue hereof.
I n W i t n e s s W h e r e o f sa id c o r p o r a tio n h a s ca u se d th is in stru m e n t to b e e x e cu te d in its b eh a lf,

pursuant to authority of its Board o f Directors, by i t s ..........................................................................,
(Official title of officer)

and its corporate seal to be hereunto attached, attested by its secretary or assistant secretary, this
day of

........... ......................................... , 19...

[IMPRESS SEAL HERE]

(Name of corporation)

B y ................-

(Official signature of officer)

Attest :
Secretary.

(Official title of officer)

Personally appeared before me the above-named ___________________________________________
known or proved to me to be the same person who executed the foregoing instrument and to be the
........................... .............. ...........................................................o f .................. ...................... ........................... .................................,
(Title of officer)

(Name of corporation)

a n d a c k n o w le d g e d to m e th a t h e e x e cu te d th e sa m e a s h is f r e e a c t a n d deed and th e fr e e a ct and deed
o f sa id c o r p o r a tio n .
W it n e s s m y sig n a tu re , official d e s ig n a tio n , a n d seal.

(Signature of attesting officer)

[ im p r e s s s e a l h e r e ]
(Official designation)

Dated a t __________________________________ , th is--------------- day o f __________________ , 19........
My commission expires___________________________, 19____

IMPORTANT.— Do not execute this instrument without first reading the instructions on the reverse side hereof.
http://fraser.stlouisfed.org/
Exact compliance with these instructions will avoid complications.
1 6 ---- 4 9 4 2 3 - 1
Federal Reserve Bank of St. Louis

F o r m P .D . 1042
TREASURY DEPARTMENT
T r e a s u r e r , U. S.
(Revised Dec. 1941)

RESOLUTION BY CORPORATION CONFERRING AUTHORITY UPON AN OFFICER TO
EXECUTE A POWER OF ATTORN EY FOR THE COLLECTION OF CHECKS
FOR INTEREST ON OR PRINCIPAL OF SECURITIES REGISTERED
ON BOOKS OF TREASU RY DEPARTMENT

Resolved, T h a t___________________________________________________________________ does hereby
(Exact corporate name)

n a m e _____________________________________________________ as attorney, with power o f substitution,
(Name o f attorney)

to receive, receipt for, indorse, and collect checks, whether for interest on, or principal of, any and
a ll United States securities and other securities w ith respect to which the Treasury Department acts
a s the transfer agency, now registered or heretofore or hereafter registered, in the name of said

corporation and to give full discharge therefor.

And it is further resolved, That f ____________________________________________________ is hereby
(Title or name and title o f officer)

authorized and empowered to execute, in behalf o f _________________________________________________ ,
(Exact corporate name)

a power o f attorney appointing the s a id ____________________________________________________________
(Name of attorney)

a s such attorney fo r the purpose above expressed.:):
I HEREBY CERTIFY that the foregoing is a true and correct copy o f a resolution passed a t a

______________________________ meeting o f the Board o f _________________________ , the governing body
(Regular or special)

o f _____ _____ _____________________________________________________ , a corporation duly organized and
(Exact corporate name)

existing under and by virtue o f the laws o f ____________________________, held on t h e ___________ day
o f _______________________ , 19____ , a t ____________________________________ ;

and

I f u r t h e r c e r t if y

that due notice o f said meeting was given to each member o f said B oa rd ; that a quorum was present,
and that said resolution has not been amended or repealed.
W i t n e s s my signature and the seal o f said corporation, t h is ____ day o f _____ ;________ , 19____

[IM PRESS CORPORATE SEAL HERE]

’

(Official signature o f officer)

(Official title o f officer)

IM PORTANT.— Do not execute this instrument without first reading the instructions on the reverse side hereof.
Exact compliance with these instructions will avoid complications.


http://fraser.stlouisfed.org/ instructions.
t See p aragrap h 4 o f
Federal Reserve Bank of St. Louis

t See paragraph 5 o f instructions.

16----- 4 9 4 2 3 -1

Standard Form No. 1055 —Revised
Form prescribed by Comp. Gen., U. S.

General Regulations No. 104

(R ea d carefu lly Instructions on reverse)

CLAIM AGAINST THE UNITED STATES
FOR AMOUNTS DUE IN THE CASE OF A DECEDENT

1. I/w e, the undersigned, hereby make claim a s __________________________ for amounts due from the
(Relationship)

United States in the case o f ------------------------------------------------ ------ --------------------------------- who died
(Name of decedent)

on t h e ________ day o f --------- ----- ----------------- , 19-----2. At the time of death the decedent was a legal resident of _______________________________ _______ ,
State o f _________________________________ and was connected with the United States as follows:
(If civilian employee, or public creditor, give name of department and bureau)

3. Are you the person entitled to receive payment for accrued and current annual leave, having been
designated as beneficiary under the Retirement Act applicable to the decedent’s service? ...............,
( “ Yes” or “ No.” ) (See par. (c) of Instructions.)
4. Has there been or will there be appointed an executor or administrator o f the decedent’s estate?
________ __ ( “ Yes” or “ No.” )
5. The deceased is survived by the following:
Widow or widower (if none, so state) :

Children (if none, so state) :

Name

Name

Grandchildren (list ONLY the children of DECEASED children— if none, so state) :
Name o f grandchild

Name o f deceased parent

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

A ddress

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

Name

Nephews and nieces (list ONLY the children of DECEASED brothers or sisters— if none, so state)
Name o f nephew or niece

Name o f deceased parent

6. Have the funeral expenses been p a id ?.................. ( “ Yes” or “ No.” )
(I f paid, receipted bill of the undertaker must be attached hereto.)
 money was used to pay the funeral expenses?________________
7. Whose


16— 4 9 423-1

The following statement (paragraph 8) should be filled in
only if an executor or administrator has been appointed
8. I/w e have been duly appointed______________________________________ of the estate of the deceased,
(Executor or administrator)
«
as evidenced by certificate of appointment herewith, administration having been taken out in
the interest o f --------------------------------------------------------- --------------------------------------------------------------(Name, address, and relationship o f interested relative or creditor)

and such appointment is still in full force and effect.
CERTIFICATES
Date__________________________
9. I/we, the undersigned claimant (s) certify that the statements herein have been examined by me/us
and that such statements are true to the best of m y/our knowledge and belief.
(Signature o f claimant)

(Signature o f claimant)

Address----------------------------------------------------------

----------------------------------------------

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

10. We certify that we are well acquainted with the above ---------------------------------------------------------------- ,
(Names of claimants)

the claimant(s) herein, and that signature (s) of the claimant(s) was (were) affixed in our pres­
ence.
(W itness to signature by " X ” mark) •

(Signature o f corroborating witness)

Address_____________________________ _________

Address__________________________

(W itness to signature by “ X ” m ark)

(Signature o f corroborating witness)

Address______________________________________ Address_______________________________________
INSTRUCTIONS
(а) Amounts in excess o f $1,000 may be paid only to the legal representative of the estate of the
deceased, duly appointed by the court having probate jurisdiction in the decedent’s last domicile, or as
may be ordered by such court; provided, however, that payment for accumulated and current accrued
annual leave may be made in any amount, without administration, to a claimant designated as beneficiary
under the Retirement Act applicable to the decedent’s service.
(б ) If a legal representative has been or will be appointed, no payment, except for accumulated and
current accrued annual leave, may be made to any other person. In making claim as legal representative
only paragraphs 1, 2, 3, 8, and 9 must be filled in, and no witnesses are required, but a short certificate of
letters testamentary or of administration must be submitted.
(c) If claim is made only for the payment due for accumulated and current accrued annual leave, fill
in only paragraphs 1, 2, 3, 9, and 10.
( d) All signatures by “ X ” mark must be witnessed.
(e) All unnegotiated Federal checks in possession of the claimant, drawn to the order o f the
decedent, should accompany the claim.




riNG O F F IC E

16— 4 9 4 2 3 -1

F o r m 1310
TREASURY DEPARTMENT
I n t e r n a l R e v e n u e S e r v ic e '

July 1945

STATEMENT OF CLAIMANT TO REFUND DUE ON BEHALF OF DECEASED TAXPAYER

(Date statement is executed)

(Name of deceased taxpayer)

1. I ? ............ ....................................... .................................................................... , hereby certify that I am the
____________________________ _______ of the deceased taxpayer and hereby make request for refund of
(Relationship or other capacity)

the income taxes overpaid by or in behalf of the decedent.
2. At the time of death was the decedent a member of the military or naval forces of the United States or any
of the other United Nations?----------- :______
(Yes or no)

3. I f answer to above is “yes,” give serial number_______________________ ___
4. The income tax in question was paid b y _____________________________________________ _____
(Name and relationship)

5. Has an executor or administrator been appointed for the estate of the above-named decedent ? ---------------(Yes or no)

W ill an executor or administrator be appointed for the estate of the decedent? _____________
(Yes or no)

I f the answer to either part of question 5 is “ yes” a court certificate showing the appointment of
such officer, and that he is still acting, must be attached to this statement. I f the answer to BOTH parts
of question 5 is “no,” the following items must be filled in.
6. On the date of death (on the ................day o f --------------- -------------------, 194___ ) the decedent was a perma­
nent resident (or domiciled) in the City of .....------- ------_____ ----------, County o f ______________ _______ ,
and State o f _____1... ........ .....................—
answered,)

(I f decedent was in military service this question need not be

7. If decedent was a member of armed forces on date of death: Proof of death, if not previously submitted
for income tax purposes, must accompany this document and may be the original or an authentic copy of
a telegram or letter from the War or Navy Department notifying the next of kin of his death while in
active service, or a certificate of death issued by an appropriate officer of the War or Navy Department.

If the decedent was in civil life on date of death: A certificate of death by proper authority must
accompapy this document, also the following questions must be answered: Have the funeral expenses been
paid?_____________
(Yes or n o)




8. T h e d e c e a s e d w a s s u r v iv e d b y th e f o l l o w i n g :
N am e

N am es

of

of

W

id o w or

W

( W r i t e “ N o n e ” w h e r e a p p l i c a b l e .)
A

id o w e r

A

A l l L iv in g C h ild r e n

ddress

A

ddress

N am e

ge

A ddress

With whom are children livin g?___________________ _________________

__________

Who supports the children? ..................................... .....................................

..................

N a m e o f L iv in g F a t h e r a n d L iv in g M o t h e r

A ddress

N a m e s o f B r o t h e r s a n d S is t e r s

A ddress

A ge

9. Are there any living children of deceased children ? _______________
(Yes or no)

We, the undersigned, claimant and witnesses, certify, under all penalties, fines, and forfeitures
imposed by law for the making of false or fraudulent claims against the United States or the making of
false statements in connection therewith, that the statements made herein have been examined by each of
us and that such statements are true to the best of our knowledge and belief.
/
TWO SUPPORTING WITNESSES ARE
REQUIRED:

(Signature of Witness)

(Signature of Claimant)

(Address o f W itness)

(Address o f Claimant)

(Signature of Witness)

(Address o f W itness)




16------4 9 4 3 3 * 1

U . S. GOVERNMENT M I N T I N G O T T I C I


Federal Reserve Bank of St. Louis, One Federal Reserve Bank Plaza, St. Louis, MO 63102