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SPECIFIC POWER OF ATTORNEY BY 
INDIVIDUAL FOR THE COLLECTION  
OF A SPECIFIED CHECK DRAWN ON THE 
UNITED STATES TREASURY

Know all by these Present:
That the undersigned, ____________________________________, of _______________________________________________
                                                                                             ( Address )
does hereby appoint  ____________________________________, of _______________________________________________
                                                                                             ( Address )
as his/her attorney to receive, endorse, and collect check No. _________________________________________________, 
dated _____________________, 20__________, for ____________________________________________ dollars drawn on the 
United States Treasury, by ________________________________________________________________________ in favor of 
___________________________________________, and to give full discharge for same; hereby ratifying and confirming all 
that said attorney shall lawfully do or cause to be done by virtue hereof.

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

____________________________________________________________            ____________________________________________________________  
            (Signature of Witness)                                                  (Signature of Grantor) 

____________________________________________________________ 
            (Signature of Witness)

*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 2(a) and 2(b)

FS Form 232                        Department of the Treasury | Bureau of the Fiscal Service               December 2021
( SUPERCEDES SF 232 ( FEB 1975 )                             Page 1 of 2

SPECIFIC POWER OF ATTORNEY BY 
INDIVIDUAL FOR THE COLLECTION  
OF A SPECIFIED CHECK DRAWN ON THE  
UNITED STATES TREASURY

            INSTRUCTIONS FOR FISCAL SERVICE FORM 232 - READ CAREFULLY
                                 SEE 31 CFR Part 240 for more information

1. A specific power of attorney, which must be executed after the issuance of the check, describing the 
check in full, as prescribed in 31 U.S.C. 3727, may be used for the endorsement and collection of any 
check drawn on the United States Treasury.

2(a). Where desirable or where required by foreign, state or local law this power of attorney should be 
acknowledged by the grantor in the presence of two attesting witnesses, and 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.

2(b). Where the power of attorney is acknowledged pursuant to paragraph 2(a), the seal of the attesting 
officer must always be impressed (or stamped) provided, however, that where acknowledgments 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 acknowledgment of the power.

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

3. This power of attorney is revoked by the death or incompetence 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.

4. 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.

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

FS Form 232                      Department of the Treasury | Bureau of the Fiscal Service       December 2021
( SUPERCEDES SF 232 ( FEB 1975 )              Page 2 of 2