**Judgment Fund Voucher for Payment**

1.  **Total Amount: , , .**

2.  **Submitting Agency Contact Name:**

> Telephone Number: **- -**

3.  **Electronic Funds Transfer (EFT) Information:**

    a.  Payee Account Name:

    b.  American Banking Association (ABA) Routing Number (9 digits):

    c.  Payee Account Number:

    d.  Checking: Savings:

    e.  Financial Institution Name, City, State:

4.  **Interagency Payment System Information:**

    a.  Agency Name:

    b.  Agency Location Code (ALC) Number: (8 digits):

    c.  Standard General Ledger (SGL) Number (4 digits):

    d.  Treasury Account Symbol (TAS):

5.  **Mailing Address for Check:** (Payee name not to exceed 32
    Characters.)

    a.  Payee Name:

    b.  Payee Name:

    c.  Address Line 1:

    d.  Address Line 2:

    e.  City: State: Zip Code:

6.  **Taxpayer Identification Number (s):**

    a.  **b)**

7.  **Reimbursement Information for Contract Disputes Act (CDA), No FEAR
    Act, and Firefighters Fund:**

    a.  Agency Name:

    b.  Contact Name:

    c.  Contract Number (CDA cases):

    d.  Telephone Number: - -

    e.  Address:

    f.  City: State: Zip Code:

8.  **If payment will be made in a foreign currency please provide the
    following information:**

> Country: Currency:

9.  **FOR USE BY JUDGMENT FUND BRANCH ONLY:**

Z Number:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ J/D
Number:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ GLOWS
Code/Agency:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Claim Analyst *Signature and Date* Amount to Pay Appropriation Code

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Claim Reviewer *Initials and Date*

**FMS** FORM **197** page 1 of 2 (PREVIOUS EDITIONS ARE OBSOLETE)
DEPARTMENT OF THE TREASURY

**12-03** FINANCIAL MANAGEMENT SERVICE

**Judgment Fund Voucher for Payment**

**10. Acceptance by Claimants:**

> **NOTE: For use ONLY where the settlement is (i) for cash, (ii) in an
> amount that does not exceed \$200,000, and (iii) a court order
> approving the settlement is not warranted. For all other situations, a
> final judgment or a standard Department of Justice *Stipulation For
> Compromise Settlement And Release* must be attached.**

Each claimant/plaintiff and his/her guardians, heirs, executors,
administrators, and assigns agree to and do accept this settlement in
full settlement and satisfaction and release of any and all claims,
demands, rights, and causes of action of any kind, whether known or
unknown, including without limitation any claims for fees, costs,
expenses, survival, or wrongful death, arising from any and all known or
unknown, foreseen or unforeseen bodily injuries, personal injuries,
death, or damage to property, which they may have or hereafter acquire
against the United States of America, its agents, servants, or
employees, on account of the subject matter of the administrative claim
or suit, or that relate or pertain to or arise from, directly or
indirectly, the subject matter of the administrative claim or suit. Each
claimant/plaintiff and his/her guardians, heirs, executors,
administrators, and assigns further agree to reimburse, indemnify, and
hold harmless the United States of America, its agents, servants, and
employees, from and against any and all claims, demands, rights, and
causes of action of any kind, whether known or unknown, including
without limitation claims for subrogation, indemnity, contribution, or
lien of any kind, or for fees, costs, expenses, survival or wrongful
death that relate or pertain to or arise from, directly or indirectly,
any act or omission that relates to the subject matter of the
administrative claim or suit.

**(SIGN ORIGINAL ONLY)**

**Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

(Claimant(s) sign above)

**11. AGENCY APPROVING OFFICIAL:** This claim has been fully examined in
accordance with Statutory Citation and approved in the amount of \$

Authorized Signature:

Title:

Date:

**FMS** FORM **197** page 2 of 2 (PREVIOUS EDITIONS ARE OBSOLETE)
DEPARTMENT OF THE TREASURY

3.  FINANCIAL MANAGEMENT SERVICE

# Judgment Fund

**Instructions for FMS Form 197: Voucher for Payment**

## Please note that FMS Form 197 is a two page form

**Item 1:** Provide the amount due to payee (requests for separate
payments require separate FMS Forms 197).

**Item 2:** Provide the name and telephone number for the Federal agency
or office that submitted the claim(s).

**Item 3:** Provide information to enable the payment by means of
Electronic Funds Transfer (EFT). This information should be provided
unless the payment is to be made by check. **Note:** **31 C.F.R. § 206.4
directs agencies to make payments by EFT whenever cost-effective,
practical, and consistent with the law, and adds that the Treasury
Department may require agencies to justify the use of non-EFT payment
mechanisms. All fields in item 3 must be completed.**

**Item 4:** Provide the name of the Federal agency, Agency Location Code
(ALC), Standard General Ledger (SGL) code, and Treasury Account Symbol
(TAS).

**Item 5:** Provide information to enable the payment to be issued by
check and to be mailed by the U.S. Postal Service either to the
Submitting Agency or directly to the claimant/plaintiff. Do not exceed
32 characters per line for the payee name(s) and address.

**Item 6:** Provide the Taxpayer Identification Number (TIN) for each
payee.

**Item 7:** Provide this item for Contract Disputes Act (CDA), No FEAR
Act, and Firefighters Fund payments.

**Item 8:** Provide this item only if the payment is to be made in
foreign currency.

**Item 9:** To be completed by the Judgment Fund Branch.

**Item 10:** This part need not be completed when another, separate,
legally sufficient settlement agreement is signed by the claimant and a
copy is submitted with the payment request.

**Item 11:** To be completed by the agency approving official, if FMS
Form 197 is used as the settlement agreement.

**FMS** FORM **197 I** (PREVIOUS EDITIONS ARE OBSOLETE) DEPARTMENT OF
THE TREASURY

**12-03** FINANCIAL MANAGEMENT SERVICE