Effective Dates: 04/18/2014 - Present Previous | Next

Basic (04-14)

NL 03001.055 Request for Check Information and Payee Signature Letter

A. When to use letter

Use this letter to request a signature specimen and question response from the beneficiary or recipient prior to requesting the handwriting analysis from the Department of the Treasury in limited payability cases per GN 02401.910.

NOTE: Please include the cover notice located in NL 03001.060 to complete the package you send to Treasury. Treasury will return the entire package if the cover letter is not included.

B. Check information and payee signature letter

Check Information and Payee Signature Letter

 

WARNING: Title 18, Sec. 287, U.S. Code: Whoever makes or presents to any person or officer in the civil, military or naval service, of the United States, or to any department or agency thereof, any claim upon or against the United States, or to any department or agency thereof, knowing such claim to be false, fictitious, or fraudulent, shall be fined not more than $10,000 or imprisoned not more than five years, or both.

1. Did you receive this check?

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2. Did you sign your name on this check?

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3. Did you cash this check?

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4. Did you deposit this check in a bank, credit union other financial organization? Did someone else deposit this check to an account that you could use?

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5. Was this check cashed with your permission?

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6. Did you receive any money or benefit in any way from this check (e.g. household expenses, child support, etc.)? If so, explain, (include amount if known).

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7. If your present name is different from that on the face of the check, Explain why.

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8. If you are making claim for this check and it is not made out to you, state your relationship to the payee. Explain why the payee cannot sign.

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Signature Boxes

 

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Date:____________________________________________________________________

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0903001055
NL 03001.055 - Request for Check Information and Payee Signature Letter - 04/18/2014
Batch run: 01/15/2025
Rev:04/18/2014