LEAD. TRANSFORM. DELIVER.

Judgment Fund

1. Total Amount: _______________________

***If payment will be made in a foreign currency, provide the following information:

Country:__________________________________ Currency:_________________________________

Pursuant to 31 CFR part 208, Judgment Fund payments are to be made by electronic funds transfer (EFT).

2. Electronic Funds Transfer (EFT) Information:

a) Payee Account Name: ___________________________________________________________________

b) Payee Address: _________________________________________________________________________

c) American Banking Association (ABA) Routing Number (9 digits): ________________________________

d) Payee Account Number: __________________________________________________________________

e) Checking: Saving:

f) Financial Institution Name: _______________________________________________________________

g) Financial Institution City & State: __________________________________________________________

h) Swift Code: ______________________ IBAN: ____________________________ (foreign payment only)

3. 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: _____________

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. 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: _____________

g) Email Address: ___________________________________________________________

6) Taxpayer Identification Number (social security number (SSN) for individuals, employer identification

number (EIN) for businesses) for each additional Party Entitled to Payment:

a) Name: ______________________________________________ SSN or EIN: _______________________

b) Name: ______________________________________________ SSN or EIN: _______________________

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(Previous Editions are Obsolete) Department of the Treasury | Bureau of the Fiscal Service Revised August 2020
LEAD. TRANSFORM. DELIVER.

Judgment Fund

Acceptance by Claimants:

NOTE: For use ONLY where the settlement is (i) for cash, (ii) in an amount that does not exceed $200,000.00, 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 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)

AGENCY APPROVING OFFICIAL:

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(Previous Editions are Obsolete) Department of the Treasury | Bureau of the Fiscal Service Revised August 2020

Authorized Signature:

Printed Name:

Title:

Date:

This claim has been fully examined in accordance with Statutory Citation

_____________________ and approved in the amount of $____________

Date: ____________________________________

Date: ____________________________________

____________________________________________

(Printed Name)

____________________________________________

(Claimant(s) sign above

____________________________________________

(Printed Name)

____________________________________________

(Claimant(s) sign above)