Fms Form 233 - Special Power Of Attorney By Individual For The Collection Of Checks Drawn On The United States Treasury

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Special Power of Attorney
BY INDIVIDUAL FOR THE COLLECTION OF
U
S
T
CHECKS DRAWN ON THE
NITED
TATES
REASURY
Know all by these Presents:
That the undersigned, ____________________________ , of _______________________________________________
(address)
does hereby appoint _____________________________ , of _______________________________________________
(address)
as his/her attorney to receive, endorse, and collect checks payable to the order of the undersigned, drawn on the United States
Treasury and issued for ________________________________________________________
(Purpose for which checks are issued)
and to give full 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.
DURABILITY OF THIS POWER OF ATTORNEY:
Initial the appropriate line. If the grantor fails to initial in front of any option, (a) shall be presumed.
_____ a. This Power of Attorney shall automatically be revoked upon a determination that I, the grantor, am
incompetent.
_____ b. This Power of Attorney shall remain effective to the extent authorized by 31 CFR Part 240 following a
determination that I, the grantor, am incompetent.
_____ c. This Power of Attorney shall become effective upon a determination that I, the grantor, am incompetent
and shall remain effective to the extent authorized by 31 CFR Part 240.
WITNESS the signature of the undersigned, this _________day of __________________ , 20 ____
________________________________
(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.
WITNESS my signature, official designation, and seal.
________________________________
(Signature of attesting officer)
[IMPRESS SEAL HERE]
________________________________
(Official designation)
Dated at ____________________ , this ______ day of ____________________ , 20 _____
My commission expires ______________________ , 20 _____
IMPORTANT – Do not execute this instrument without first reading the instructions on the next page.
Exact compliance with these instructions will avoid complications.
* See Instructions on next page – Paragraphs 3(a) and 3(b)
DEPARTMENT OF THE TREASURY
FORM
FMS
233
(SUPERSEDES SF 233 (JANUARY 1976)
FINANCIAL MANAGEMENT SERVICE
1-04

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