Scribd
Upload
158 views

Claimant Form

Insurance Claimant Form

Uploaded by

job.cnd
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
158 views

Claimant Form

Insurance Claimant Form

Uploaded by

job.cnd
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

Standard Form 1055

Rev. March 1999


Title 4, GAO Manual

&/$,0$*$,1677+(81,7('67$7(6
)25
$028176'8(,17+(&$6(2)$'(&($6('&5(',725

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
2. The basis of this claim is as

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

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


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

7:2:,71(66(6$5(5(48,5('

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)

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.
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.

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy