Fs Form 1201w - Request For Payment Of Federal Benefits By Check printable pdf download

Request for Payment of Federal Benefits by Check

FS Form 1201W (March 2014) Previous versions obsolete.

Federal law (31 U.S.C. 3332 and 31 CFR 208) requires that all Federal benefit and other nontax payments be made electronically.

To receive your payments by check, you must explain how you qualify for a waver by submitting this certified Request for Waiver to the U.S. Department

of the Treasury.

•

DIRECTIONS

Complete boxes A, B, C, and D.

Submit the completed original form to the U.S. Treasury

Electronic Payment Solution Center at the address found

•

This Request for Waiver must be signed by the payment

at the bottom of this form.

recipient. In cases where a representative payee has

•

Incomplete forms cannot be processed.

been designated, the representative payee is the

payment recipient who should sign the form.

FEDERAL PAYMENT RECIPIENT INFORMATION

WAIVER REQUEST

(one form for each check received)

(print name[s] and address exactly as they appear on your benefit check)

NAME OF THE PERSON ENTITLED TO GOVERNMENT BENEFITS (BENEFICIARY)

TYPE OF FEDERAL BENEFIT:

Receiving payments electronically will impose a hardship on me

because (check one):

REPRESENTATIVE PAYEE?

NAME OF REPRESENTATIVE PAYEE

Yes

(If Yes enter

I am unable to manage an account at a financial institution or a

name at right)

Direct Express® card account due to a mental impairment.

ADDRESS (street, route, P.O. Box, apartment number)

I am unable to manage an account at a financial institution or a

Direct Express® card because I live in a remote geographic

CITY (or APO / FPO)

STATE

ZIP CODE

location lacking the infrastructure to support electronic financial

transactions.

DAYTIME TELEPHONE NUMBER

I was born on or before May 1, 1921.

My date of birth is:

mm / dd / yy

SOCIAL SECURITY NUMBER OF PERSON ENTITLED TO GOVERNMENT BENEFITS (BENEFICIARY)

CLAIM NUMBER

REQUEST FOR WAIVER SUPPORTING INFORMATION

Please write 1-2 sentences to explain why your mental impairment or remote geographic location makes you unable to receive payments electronically.

CERTIFICATION

I certify that all of the statements in this Request for Waiver are true. I understand that any person who knowingly or willfully makes false or fraudulent

statements or representations to the United States government in connection with this Request for Waiver may be subject to fines and / or

imprisonment (18 U.S.C. §§ 1001).

SIGNATURE

DATE

PRIVACY ACT NOTICE: Collection of the information in this Request for Waiver is authorized by

Be sure to complete all sections

5 U.S.C. § 552a, 31 U.S.C. § 3332(g), and Executive Order 9397 (November 22, 1943). Your social

of this form. Otherwise, the form

security number and the other information requested will allow the federal government to process your

cannot be processed.

request for a waiver. Your social security number is requested to ensure the accurate identification and

retention of records pertaining to you and to distinguish you from other recipients of federal payments.

Return the completed form to:

This information will be disclosed to the Department of the Treasury and its fiscal and financial agents,

U.S. Treasury

and other federal agencies, as necessary to process your request for a waiver. This information may

Electronic Payment Solution Center

also be disclosed to a court, congressional committee or another government agency as authorized

or required to verify your receipt of federal payments. Although providing the requested information

P.O. Box 650015

is voluntary, your request for waiver cannot be processed without it.

Dallas, TX 75265-0015

Fs Form 1201w - Request For Payment Of Federal Benefits By Check

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