Standard Form 1055

Rev. March 1999

Title 4, GAO Manual

	



	

	





	

		


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

United States in the case of

(Relationship)

(Name of decedent)

who died on the day

of , , while domiciled in the State of

2. The basis of this claim is as

3. Has there been or will there be appointed an executor or administrator of the decedent's estate?

("Yes" or "No".) If the answer is "Yes," the following statement should be completed:

I/we have been duly appointed (Executor or Administrator)

of the estate of the deceased, as evidenced

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

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

(State nature of claim, amount, name and location of Department or Agency involved)

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 byName

Widow or widower (if none, so state):

Children (if none, so state):

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

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

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

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):

Mother (if deceased, so state):

Brothers and sisters (if none, so state):

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

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.

(Date) (Signature of claimant) (Date)



			


We certify that we are well acquainted with the (Name of claimant (s))

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

(Signature of witness) (Signature of witness)

(Street address) (Street address)

(City, State, and ZIP code) (City, State, and ZIP code)

(Street address) (Street address)

(City, State, and ZIP code) (City, State, and ZIP code)

All unnegotiated Government checks in possession of the claimant, drawn to the order of the

decedent and involved in the claim, shall accompany this claim application.

(Signature of claimant)
 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

(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

 (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

(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

(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

(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

(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.