Standard Form 1055

September 1967

Title 4, GAD Manual

1055-105

# CLAIM AGAINST THE UNITED STATES

FOR

AMOUNTS DUE IN THE CASE OF A DECEASED CREDITOR

1\. I/we, the undersigned, hereby make claim as \--
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ for amounts due from the

> (Relationship)

United States in the case of
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ who
died on the \_\_\_\_\_\_\_\_\_ day

> (Name of decedent)

of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ , \_\_\_\_\_\_\_\_\_\_ while
domiciled in the State of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

(Month) (Year)

2\. The basis of this claim is as follows:

3\. I/we have been duly appointed
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ of the estate of the
deceased, as evidenced

(Executor or Administrator)

by certificate of appointment herewith, administration having been taken
out in the interest of:

(Name, address, and relationship of interested relative or creditor)

and such appointment is still in full force and effect.

(If making claim as the executor or administrator of the estate of the
deceased, no witnesses are required, but a short certificate of letters
testamentary or of administration must be submitted.) (If you are the
executor or administrator of the estate of the deceased, disregard
paragraphs 4, 5, and 6.)

4\. If an executor or administrator has not been or will not be
appointed, the following information should be furnished: The deceased
is survived by-

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Name

Widow or widower (if none, so state):

Children (if none, so state):

### Name Age (if under 21) Street Address City, State, and ZIP Code

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Grandchildren (list only the children of deceased children-if none, so
state):

## Name Age (if under 21) Street Address, City, State, and ZIP Code Name of deceased parent of grandchild 

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

> Name *Street Address, City, State, and ZIP Code*

Father (if deceased, so state): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Name *Street Address, City, State, and ZIP Code*

Mother (if deceased, so state): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Brothers and sisters (if none, so state): Name Age (@f under 21)

Nephews and nieces (list only the children of deceased brothers or
sisters\--if none, so state) -

Name *Age (if under 21) Street Address, City, State, and ZIP Code Name
of deceased parent of nephew or niece*

5\. Have the funeral expenses been paid? \_\_\_\_\_\_\_\_ ("Yes," or
\"No.\") *(If paid, receipted bill of the undertaker must be attached
hereto.)*

6\. Whose money was used to **pay** the funeral expenses?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*(If funeral expenses were paid from the proceeds of an **insurance
policy**, state the name of the beneficiary of such policy.)*

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

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

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

Signature of claimant (Date) Signature of claimant (Date)

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

(Street address) (Street address)

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

(City, State and Zip Code) (City, State and Zip Code)

TWO WITNESSES ARE REQUIRED

We certify that we are well acquainted with the above
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> (Name of claimant(s))

and that the signature(s) of the claimant(s) was (were) affixed in our
presence.

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

(Signature of witness) (Signature of witness)

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

(Street address) (Street address)

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

(City, State and Zip Code) (City, State and Zip Code)

All un-negotiated Government checks in possession of the claimant, drawn
to the order of the decedent and involved in this claim, shall accompany
the claim application.

U.S. GOVERNMENT PRINTING OFFICE: #S-K GPO 955-079

#  INSTRUCTIONS FOR COMPLETING STANDARD FORM 1055

(Use additional paper if necessary)

1\. (a) Your relationship to the deceased

\(b\) Name of the deceased

(c) Date when the deceased died

(d) Name of the State where deceased died

2\. Completed by Treasury

3\. (a) If the estate has not been probated, put "no", Complete #4, to
end the form. If the

estate has been probated in court put "yes"

(b) Insert whether Executor or Administrator only if estate is probated

(c) Name, address, relationship of interested relative or creditor. If
    the answer is "yes", a currently dated court certificate must be
    submitted showing your appointment. If the estate has not been
    probated, the rest of the form must be completed.

4\. [Widow or Widower]{.underline}

(a) If the deceased was married, put the name of the spouse and if not
    living put

> "deceased" after the name and the date the person died. If never
> married, put "never married"

[Children]{.underline}

\(b\) List the names of all children, both living and deceased. Put
current addresses

after the names of the living children and put "deceased" after the
names of

children who are deceased. If the deceased had no children, put "none"

[Grandchildren]{.underline}

> \(c\) If any of the above children in (b) are deceased, place names
> and addresses of the
>
> children of those deceased children. Place the name of the deceased
> parent after the name of the child. If the deceased child had no
> children of their own or never married, so state.

[Father & Mother]{.underline}

(d) If no spouse or children survived the deceased, put the names of
    deceased's

> Father and mother in proper place. If deceased, put "deceased" after
> names. If
>
> Living put addresses after names.

[Brothers & Sisters]{.underline}

(e) List the names of all brothers and sisters of the deceased, both
    living and

> Deceased. Put addresses of the living brothers and sisters and put
> "deceased" after the names of the deceased brothers and sisters.

[Nephews & Nieces]{.underline}

(f) List names and addresses of the children of the deceased brothers
    and sisters

> in (e) above.

5(a) If funeral expenses are paid, put "yes". If not, put "no"

\(b\) If funeral expenses are paid, a copy of the paid funeral bill
should be

> submitted, showing who paid the bill. If the bill is not available,
>
> a statement of explanation is required.

6\. (a) The name of the person who paid the funeral bill.

\(b\) If any insurance money was used to pay the funeral bill, name of
the

> person who was the beneficiary of the insurance.

7.  Signature of applicant, date and address

8.  Signatures of two witnesses and their addresses.