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SPECIAL POWER OF ATTORNEY BY 
INDIVIDUAL FOR THE COLLECTION  
OF CHECKS DRAWN ON THE  
UNITED STATES TREASURY

Know all by these Presents:
That the undersigned, ____________________________________, of _______________________________________________
                                                                                                                                    ( Address )
does hereby appoint  ____________________________________, of _______________________________________________
                                                                                                                                   ( Address )
as his/her attorney to receive, endorse, and collect checks payable to the order of the undersigned, drawn on the 
United States Treasury and issued for _________________________________________________________
                                                                       (Purpose for which checks are issued)
and to give full discharge for the same, hereby ratifying and confirming all that said attorney shall lawfully do by virtue 
hereof. This power of attorney is not given to carry into effect an assignment to the attorney, or to any other person, of 
the right of the undersigned to receive the above-described payments.

                                      DURABILITY OF THIS POWER OF ATTORNEY

          Initial the appropriate line. If the grantor fails to initial in front of any option, (A) shall be presumed.
      ______ A. This Power of Attorney shall automatically be revoked upon a determination that I, the grantor,  
                       am incompetent.
      ______ B. This Power of Attorney shall remain effective to the extent authorized by 31 CFR Part 240 following a  
                       determination that I, the grantor, am incompetent.
      ______ C. This Power of Attorney shall become effective upon a determination that I, the grantor, am incompetent  
                       and shall remain effective to the extent authorized by 31 CFR Part 240.

WITNESS the signature of the undersigned, this __________ day of _______________________, 20____

            ____________________________________________________________________________________
                                              (Signature of Grantor) 
*Personally appeared before me the above-named ________________________________________________________________
known  or proved to me to be the same person who executed the foregoing instrument, and acknowledged to me that 
he executed the same as his free act and deed.

WITNESS my signature, official designation, and seal   ______________________________________________
                                                                                                                            (Signature of attesting officer)

[ IMPRESS SEAL HERE ]                                                ______________________________________________
                                                                                                                           (Official designation)

           Dated at  ______________________,  this __________  day of  __________________,  20____________
                                              My commission expires _______________________________,  20____________

            IMPORTANT - Do not execute this instrument without first reading the instructions on  
            the next page. Exact compliance with these instructions will avoid complications.

*See Instructions on next page, Paragraphs 3(a) and 3(b)

FS Form 233                           Department of the Treasury | Bureau of the Fiscal Service                                                             November 2021
( SUPERCEDES SF 233 ( JAN 1976 )                        Page 1 of 2



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 SPECIAL POWER OF ATTORNEY BY 
 INDIVIDUAL FOR THE COLLECTION  
 OF CHECKS DRAWN ON THE  
 UNITED STATES TREASURY

            INSTRUCTIONS FOR FISCAL SERVICE FORM 233 - READ CAREFULLY
                                   SEE 31 CFR Part 240 for more information

 1. A power of attorney using this form may be executed as authority for the endorsement and collection of checks  
     drawn on the United States Treasury for purposes other than those identified at 31 CFR 240.16(b). This power of  
     attorney must name the attorney-in-fact and must recite that it is not given to carry into effect an assignment to the  
     attorney-in-fact, or to any other person, of the right to receive the payments therein described.

 2. The grantor should explicitly indicate whether he/she intends:
     (a). The power of attorney to automatically revoke if the grantor is determined to be incompetent;
     (b). The power of attorney to remain effective despite a determination that the grantor is incompetent to the extent  
           authorized by 31 CFR Part 240; or
     (c). The power of attorney to become effective only upon a determination that the grantor is incompetent and to  
           remain effective as long as authorized by 31 CFR Part 240.

     If the grantor fails to clearly indicate his/her intent on the power of attorney, the power of attorney shall automatically  
     revoke upon a determination that the grantor is incompetent.

3(a). Where desirable or where required by foreign, state or local law this power of attorney should be acknowledged  
          before a notary public or other officer authorized by law to administer oaths generally. If in a foreign country, the  
          acknowledgment should be made before a United States diplomatic or consular representative. If such an officer  
          is not available, it may be acknowledged before a notary or other officer authorized to adminster oaths, but his  
          official character and jurisdiction must be certified by a United States diplomatic or consular officer, under the  
          seal of his office.

3(b). Where the power of attorney is acknowledged pursuant to paragraph 4(a), the seal of the attesting officer must  
          always be impressed (or stamped) provided, however, that where acknowledgements before a notary public,  
          or other officer authorized by law to administer oaths, are not thus authenticated by the official impression seal  
          of such officer, the power should be accompanied by a certificate from the proper official showing that the officer  
          was in commission on the date of the acknowledgement. The date when the officer’s commission expires should  
          appear in any event. If a certificate is furnished, such certificate should show the dates of the beginning and end  
          expiration of the officer’s commission, and such period of commission should include the date of  
          acknowledgement of power.

3(c). Notwithstanding the foregoing, persons subject to military jurisdiction may acknowledge powers of attorney 
before officers specially designated for that purpose pursuant to law.

4. This power of attorney is revoked by the death of the grantor and may also be revoked by notice from the grantor to 
the parties concerned. Notice of revocation to the Treasury will not ordinarily serve to revoke the power.

5.  If it is desired that checks be mailed to the attorney instead of to the payee, formal notice of change in the post-
office address, identifying the checks affected, should be forwarded to the administrative office that authorized 
issuance of the checks.

6. POWERS OF ATTORNEY NEED NOT BE FILED WITHIN THE UNITED STATES TREASURY.

FS Form 233                        Department of the Treasury | Bureau of the Fiscal Service                November 2021
( SUPERCEDES SF 233 ( JAN 1976 )            Page 2 of 2






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