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hereby prescribed for the purpose. (Secs. 309, 311 (f), 42 Stat. 25; 31 U.S.C. 49, 52 (f)) [Sec. 1, Regs. 42, Supp. 1, Feb. 23, 1928]

STATE OF---

-----} 88: COUNTY OF--1. I. -----------------

--------, being duly sworn, say that I am residing at --

----- city of ----

(Street address) county of -----

---------, and State of ---------and that on the ---------------- day of -----

-------, 19----. - had.

------- personal domicile in and (Name of d decedent or incompetent)

(His or her) was a resident of the city of --------------------, county of --------and State of ---------------------, and on said date ---------

(Died testate or died intestate or was declared incompetent) 2. That at the time of ------------ decease or incompetency ------------ was (His or her)

(He or she) connected with the United States as follows:

--------------(If civilian employee, active or retired, give name of department or establishment and bureau or office ; if an officer or enlisted man, active, retired, or pensioned, in Army, give rank

-- - - - -- - -- - -- - -- -- - - -- - - - - -- -- and organization, or if in Navy or Marine Corps, give rank, vessel or station and serial

number; if public creditor, give connection) 3. That at the time of -------- decease or incompetency there remained due

(His or her)

------ from the United States the sum of Dollars and

---- Cents ($--------------), for the payment of which application is hereby made. 4. That at the time of ---------- decease or incompetency there existed the

(His or her) following-described unpaid official checks and/or warrants, drawn to

(His or her) order as payee, and for the payment of which application is hereby made:

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and unpaid to him or her)

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5.* That I am the legally appointed -

------ of the estate

(Executor, administrator, guardian, or committee) of decedent or incompetent, as appears from the certificate of the ------Court, county of .

--------, State of herewith, taken out in the interest of

(Give name, address, and relationship of interested relative or creditor)

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or6.* That the decedent left no assets subject to administration, except the sum or sums above claimed to be due from the United States and ------

ULU

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

*In case of testacy, intestacy with administration of estate, or incompetency, fill out paragraphs 1, 2, 3, 4, 5, and 6 (j) when applicable, omitting remainder of paragraph 6 and the affidavit of corroborating witnesses.

In case of intestacy without administration of estate, fill out paragraphs 1, 2, 3, 4, and 6 (a-i) when applicable, and the affidavit of corroborating witnesses, omitting paragraph 5.

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5.2 Use of Standard Form 1055. The claims to be applied for on the standard form embrace arrears of pay, etc., of deceased or incompetent civilian employees of the various departments and inde

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(List other assets left by decedent and give approximate value)

that there has been no administration upon such estate and if this claim is paid no administration will be required, and that the answers to the following questions are true and correct to the best of my knowledge and belief: (a) What was your relationship to the intestate?

(State whether widow, husband, child, grandchild, father, mother, brother, or

sister of the whole or half blood, child of deceased brother or sister of the

whole or half blood, nephew, or niece) (b) Have the funeral expenses been paid? -(c) If so, by whom, and state amount? (d) Was payment made out of funds belonging to the estate of the intestate?

(e) If not, was payment made by you out of your own personal funds? ---(The receipted itemized bill of the undertaker must be attached hereto.)

(Back of Form No. 1055) (f) If the intestate left a surviving widow, husband, child or child of a deceased child, enter below the name of each and relationship to the intestate, together with the name of deceased child of the intestate who was the parent of surviving grandchildren.

NAME OF SURVIVOR

ADDRESS

RELATIONSHIP TO

INTESTATE

(g) If the intestate is survived by parents, enter below the name of each ; if one parent is deceased, so state; if the surviving father has abandoned the support of his family, so state.

NAME OF SURVIVOR

ADDRESS

RELATIONSHIP TO

INTESTATE

(h) If the intestate left a brother or sister of the whole or half blood, or child of a deceased brother or sister of the whole or half blood, enter below the name of each and relationship to the intestate, together with the name of deceased brother or sister of the intestate of the whole or half blood who was the parent of surviving nieces and nephews.

NAME OF SURVIVOR

ADDRESS

RELATIONSHIP TO

INTESTATE

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pendent establishments and deceased or incompetent officers and enlisted men in the military service, payments due deceased or incompetent individual contractors or other deceased or incompetent public creditors of the United States for supplies furnished or services performed, and claims of whatever character against the United States covering amounts due deceased or incompetent creditors which are for the General Accounting Office to adjust by direct settlement.

(i) Have you received the benefit of any exemption or allowance from the estate of the deceased, and if so, to what extent? ---

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

(3) State any additional facts on which you base your claim to any amount or amounts found due:

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

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

(Signature by mark must be witnessed) ---- (Signature of applicant)
(Signature by mark must be witnessed)

(Signature of applicant)
Also personally appeared before me ------ -------- and
both of ---

--, county of ---

------, State of.

-----, who, being duly sworn, say that they were well acquainted with the above-named

(Name of decedent or incompetent) and with -

------ family and affairs; that they are well acquainted

(His or her) with -----

-------- the applicant herein; that they have read the statements made by the applicant in the foregoing affidavit and that such statements are true to the best of their knowledge and belief.

at ------------------------

(Signatures by mark must be witnessed)

(Sign here) (Signatures by mark must be witnessed)

(Sign here) Subscribed and sworn to before me by applicant and corroborating witnesses

------- this ------

------- day of

---, 19 (SEAL]

Notary Public. READ CAREFULLY

Amounts due to the estates of deceased creditors of the United States are payable primarily to the executors or administrators of the estates of such creditors. In each such case a short certificate of letters testamentary or of administration, if issued, with a showing whether still in force and effect, and this application signed by the executor or administrator, shall be submitted to the proper official.

If an executor or administrator has not been and will not be appointed and an amount not in excess of $500 is due the estate of a deceased creditor of the United States, the amount due may be paid to the person or persons who under the laws of the domicile of the decedent or an applicable Federal statute would be entitled to receive the money if administration were had. In such case this form of application should be executed by such person or persons and submitted to the proper official.

In case of an incompetent creditor, a short certificate showing the appointment and qualification of a guardian or committee of the estate of the incompetent, whether bond, if required, has been given, and whether appointment is still in force and effect, and application on this form for the payment of the sum or sums from the United States, signed by the guardian or committee, shall be submitted to the proper official.

Payments to be made on this form are for the convenience and accommodation of the claimants and the burden of proving the existence of the conditions under which such payments may be made rests upon them.

10-1844

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The standard form will also be used for making claim for payment of unpaid checks or warrants drawn to the order of Government creditors as payees, but which can not be paid because of their death or incompetency. This requirement applies not only to checks drawn by disbursing officers by whatever title known, but by the Treasurer of the United States based on warrants, and to pension, civil service retirement and all other classes of Government checks drawn on the Treasurer of the United States or other authorized Government depository, except checks drawn on local banks by postmasters under authority of section 3847, Revised Statutes (amended), and interest checks on the public debt. (Secs. 309, 311 (f), 42 Stat. 25; 31 U.S.C. 49, 52 (f)) [Secs. 2, 3, Regs. 42, Supp. 1, Feb. 23, 1928]

PART 6-CHECKS AND WARRANTS TO DECEASED OR

INCOMPETENT PAYEES

Sec.

Sec. 6.1 Classification of checks, the payees 6.5 Checks which should be forwarded

of which are deceased or incompe to Chief Disbursing Officer, tent.

Treasury Department. 6.2 Checks and warrants which should 6.6 Nonapplicability of Bulletin No. 2,

be forwarded to the Comptroller 1922 to interest checks, powers of General of the United States.

attorney, and certificates of au6.3 Applications for proceeds, by whom thority to indorse warrants or to be made.

checks. 6.4 Applications for proceeds, evidence

required, and form to be used.

Section 6.1 Classification of checks, the payees of which are deceased or incompetent. (a) Checks, the payees of which are deceased or incompetent, are classified for the purposes of the disposition of their proceeds as follows:

(1) Checks drawn without vouchers, which bear underneath their number a letter or letters “A” or letter or letters “B”, and which were delivered to the payees in person, or delivered prior to the death of the payees to anyone authorized to receive them for the payees.

(2) Checks drawn without vouchers, which bear underneath their number the letter or letters “A” or letter or letters “B”, and which were not delivered to the payees in person, nor delivered prior to the death of the payees to anyone authorized to receive them for the payees.

(3) Checks drawn with vouchers and which bear underneath their number a letter or letters “C”.

(4) Checks for refundments from retirement fund; and checks to annuitants who die on or after the last day of the periods covered by the checks.

(5) Checks to annuitants who die prior to last day or periods covered by the checks.

Page 15 (6) Checks the payees of which are incompetent and for which payees committees or guardians of their estates have been appointed.* [Circ. 5, Apr. 25, 1922]

*88 6.1 to 6.6, inclusive, issued under the authority contained in secs. 309, 311 (f), 42 Stat. 25; 31 U.S.C. 49, 52 (f).

6.2 Checks and warrants which should be forwarded to the Comptroller General of the United States. (a) Checks of classes (1), (3), (4), and (6), as listed in § 6.1 should be forwarded directly to the Comptroller General of the United States, General Accounting Office, Washington, D. C., for the placing upon them of an authorization for the payment of their proceeds to the party entitled thereto as assets under the statutes of the State of the domicile of the deceased.

(b) Warrants, checks drawn by the Treasurer of the United States upon warrants, and checks drawn by disbursing officers or agents of the United States, which can not be paid because of death of original payee, disqualification, or error in name or designation of, should be forwarded to the Comptroller General of the United States, General Accounting Office, Washington, D. C., without alteration or correction, for authorization for payment to the party ascertained to be entitled to the proceeds of the warrant or check upon its indorsement by such party in the usual manner.* [Circ. 5, Apr. 25, 1922, Bull. 2, May 22, 1922]

6.3 Applications for proceeds, by whom to be made. (a) The application for classes (1), (3), and (4) checks, as listed in § 6.1, should be by the executor or administrator of the estate of the deceased, or, if none, and the amount be not over $500, by the widow of the deceased, or other person claiming the proceeds as assets under the laws of his domicile, including the undertaker in the event the funeral expenses are a preferred claim by the laws of said domicile and the bill be unpaid.

(b) The application for class (6) checks, as listed in § 6.1, should be by the committee or guardian of the estate of the incompetent.

(c) The party to whom the warrant or check will be authorized payable upon indorsement in the usual manner is

(1) In case of death or incompetency, the one entitled thereto under the laws of the domicile of the State of the deceased, in the absence of a Federal statute of distribution applying to the particular case, or the one entitled pursuant to such Federal statute if there be one.

(2) In case of error in name or designation, the payee by correct name or designation.* [Circ. 5, Apr. 25, 1922, Bull. 2, May 22, 1922]

6.4 Applications for proceeds, evidence required, and form to be used. Evidence to accompany checks forwarded to Comptroller General.

(a) Checks of class (1). Class (1) checks, as listed in § 6.1, should be accompanied by a short certificate of letters testamentary or of administration, with a showing whether still in force and effect; or, if such letters have not been and will not be issued, and

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*For statutory citation, see note to g 6.1.

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