Fill and Sign the Us Bank Power of Attorney Form

Judgment Fund Voucher for Payment 1. Total Amount: ____,____,____,.___ 2. Submitting Agency Contact Name: Telephone Number: ____-____-________ 3. Electronic Funds Transfer (EFT) Information: a) Payee Account Name: b) American Banking Association (ABA) Routing Number (9 digits): c) Payee Account Number: d) Checking: Savings: e) Financial Institution Name, City, State: 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. 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: __________ 6. Taxpayer Identification Number (s): a) ______________________________ b) _____________________________ 7. Reimbursement Information for Contract Disputes Act, 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: __________ 8. If payment will be made in a Foreign Currency, please provide the following information: Country: Currency: 9. FOR USE BY JUDGMENT FUND BRANCH ONLY: Z Number: J/D Number: Claim Analyst Signature and Date GLOWS Code/Agency: Amount to Pay Appropriation Code Claims Reviewer Initials and Date FMS FORM 11-03 197 DEPARTMENT OF THE TREASURY PAGE 1 OF 2 (PREVIOUS EDITIONS ARE OBSOLETE) FINANCIAL MANAGEMENT SERVICE Judgment Fund Voucher for Payment 10. Acceptance by Claimants: NOTE: For use ONLY where the settlement is (i) for cash, (ii) in an amount that does not exceed $200,000, 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 do 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, 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) Date ________________________ (Claimant(s) sign above) 11. AGENCY APPROVING OFFICIAL: This claim has been fully examined in accordance with Statutory Citation ___________________________________ and approved in the amount of $ _____________ Authorized Signature: Title: Date: FMS FORM 11-03 197 DEPARTMENT OF THE TREASURY PAGE 2 OF 2 (PREVIOUS EDITIONS ARE OBSOLETE) FINANCIAL MANAGEMENT SERVICE Judgment Fund Instructions for FMS Form 197: Voucher for Payment Please note that FMS Form 197 is a two-page form Item 1: Provide the amount due payee (requests for separate payments require separate FMS Forms 197). Item 2: Provide the name and telephone number for the Federal agency or office that submitted the claim(s). Item 3: Provide information to enable the payment by means of Electronic Funds Transfer (EFT). This information should be provided unless the payment is to be made by check. Note: 31 C.F.R. § 206.4 directs agencies to make payments by EFT whenever cost-effective, practical, and consistent with the law, and adds that the Treasury Department may require agencies to justify the use of non-EFT payment mechanisms. All fields in Item 3 must be completed. Item 4: Provide the name of the Federal agency, Agency Location Code (ALC), and Standard General Ledger (SGL) code. Item 5: Provide information to enable the payment to be issued by check and to be mailed by the U.S. Postal Service either to the Submitting Agency or directly to the claimant/plaintiff. Item 6: Provide the Taxpayer Identification Number (TIN) for each payee. Item 7: Provide this item for Contract Disputes Act (CDA), No FEAR Act, and Firefighters Fund payments. The address for the Chief Financial Officer (CFO) should be provided for No FEAR Act payments. Item 8: Provide this item if the payment is to be made in a foreign currency. Item 9: To be completed by the Judgment Fund Branch. Item 10: This part need not be completed when another, separate, legally sufficient settlement agreement is signed by the claimant and a copy is submitted with the payment request. Item 11: To be completed by the agency approving official, if FMS Form 197 is used as the settlement agreement. FMS FORM 11-03 197 I DEPARTMENT OF THE TREASURY (PREVIOUS EDITIONS ARE OBSOLETE) FINANCIAL MANAGEMENT SERVICE