Reset

                                 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 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)
FORM                                                                                            DEPARTMENT OF THE TREASURY
FMS       1-04 233(SUPERSEDES SF 233 (JANUARY 1976)                                                          FINANCIAL MANAGEMENT SERVICE

   INSTRUCTIONS FOR FMS 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 administer 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 acknowledgment. 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
   expiration of the officer’s commission, and such period of commission should include the date of acknowledg-
   ment of the 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 WITH THE UNITED STATES TREASURY.