Fill and Sign the New Jersey Assignment of Benefits Form

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 Father (if deceased, so state): Street Address, City, State, and ZIP Code __________________ Name _________________________________ Street Address, City, State, and ZIP Code Mother (if deceased, so state): __________________ Brothers and sisters (if none, so state): Name _________________________________ Age (if 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) (b) (c) (d) Your relationship to the deceased Name of the deceased Date when the deceased died 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. 8. Signature of applicant, date and address Signatures of two witnesses and their addresses.