Request for Payment of Federal Benefits by Check

FS Form 1201W-DFAS (April 2014) Previous versions obsolete.

Federal isw (31 U.9.C. 3332 snd 31 CFR 208) requires Inst st Fecersi beneft and omer nontax payments be made electronically.

To receive your payments by check, you must explain now you quality for a waver by Submitting this certified Request for Waiver to the U.S. Department

of the Treasury.

DIRECTIONS * Complete boxes A, 5, C, and D.

* This Request for Waiver must be signed by the payment
fecipient in cases where a representative payee nas
been designated, the representative payee Is the
payment recipient who should sign the form.

A. FEDERAL PAYMENT RECIPIENT INFORMATION
(beint namefs} anc address exacty as ey appear on your benefe Check)

+ Suommt the completed original form to the U.S. Treasury
Electronic Payment Solution Center at he address found
at the bottom of mis form.

© Incomplete forms cannot be processed.

B. WAIVER REQUEST (one form for each check received

NAME OF THE PERSON ENTITLED TO GOVERNMENT SENEFITS (BENEFICIARY)

 emnee | JaNNurant | JFoRMeR spouse

ADDRESS (street, route, P.0. Bex, apartment number}

CITY for APO / FPO) STATE 2P COOE

DAYTIME TELEPHONE NUMBER

Receiving payments electronically will Impose a hardship on me
because (check one}:

1am unable to manage an account at a financial Institution or a
Direct Express® card account due to a mental Impairment.

am unabie to manage 3n account at a financial insttuton or a
Direct Express® caro because | live in a remote

location lacking the infrastructure to suppor electronic financial
transactions.

Iwas bom on or before May 1, 1921
My date of birth is:

mim 700777

SOGAL SECURITY NUMBER OF PERSON ENTITLED TO GOVERNMENT BENERTS:

CLALIT

REQUIRED FOR ANNUITANTS AND.
PROVIDE THE SOCIAL ScCUTY MER OF De DECEASED SPOURE OR HE ETRE.

CIOL

C. REQUEST FOR WAIVER SUPPORTING INFORMATION

Please wmte 1-2 sentences to expiain what circumstances make you unabie to receive payments electronically.

D. CERTIFICATION

Imprisonment (16 U.S.C. §§ 1001).

Toertty that af of the statements in this Request for Walver are true. | understand that any person who Knowingly or wilfully makes false or fraudulent
statements or representatons to the United States government in connection with this Request for Walver may be subject fo fines and / or

SIGNATURE

DATE

Be sure to complete all sections
of this form. Otherwise, the form

cannot be processed.

Return the completed form to:

U.S. Treasury

Electronic Payment Solution Center
P.O. Box 650015

Dallas, TX 75265-0015

PRIVACY ACT NOTICE: Collection of the Information In this Request for Walver Is authorized by
SU.S.C. § 52a, 31 U.S.C. § 333219), an and Executive Order 9387 (November 22, 1943). Your sociat
securty number and the other information
request for a waiver. Your social security number Is requested to ensure the accurate

retention of records pertaining to you and to distinguish you from other recipients of federal payments.
This information wif be disclosed to the Department of the Treasury and Its fiscal and financial agents,
and other federal agencies, as necessary to process your request for a waiver. This Information may
also be disclosed to a court, congressional

oF required to vertty your receipt of federal payments. Although providing the requested information
is voluntary, your request for waiver cannot be processed without It.

Tequested will allow the federal government to process your
Identification and

committee or another government agency as authorized