Fillable Printable Voucher For Payment Under Federal Tort Claims Act

Voucher For Payment Under Federal Tort Claims Act

SIGN

ORIGINAL

ONLY

VOUCHER FOR PAYMENT

UNDER FEDERAL TORT CLAIMS ACT

Standard Form 1145 (EG)

(Revised 1/92)

Department of the Treasury

1 TFM 4-2000

Voucher No.

Schedule No.

Claim No.

U.S.

(Department, bureau, or establishment)

(Give place and date)

(Payee(s))

Voucher prepared at

The United States, Dr.,

PAID BY

Address

Amount claimed, $

Amount of award, compromise, or settlement -

BRIEF DESCRIPTION OF CLAIM (See attachments for further explanation in detail.)

Date

, 20

Title

Paid by Check No.

Date

SIGN ORIGINAL ONLY

This claim has been fully examined in accordance with the provisions

of the Federal Tort Claims Act (28 U.S.C. 2673), and is approved in the

(Claimant)

, 20

I, (We), the claimant(s) and beneficiaries, do hereby accept the within-stated award, compromise, or settlement as final and conclusive on

me (us), on my (our) heirs, executors, administrators or assigns, and agree that said acceptance constitutes a complete release by me (us), on

my (our) heirs, executors, administrators or assigns of any and all claims, demands, rights, and causes of action of whatsoever kind and nature,

arising from, and by reason of any and all known and unknown, foreseen and unforeseen and bodily and personal injuries, damage to property

and the consequences thereof, resulting, and to result, from the same subject matter that gave rise to the claim for which I (we) or my (our)

heirs, executors, administrators, or assigns, and each of them, now have or may hereafter acquire against the United States and against the

employee(s) of the Government whose act or omission gave rise to the claim by reason of the same subject matter, including any future claim

for the wrongful death of me (us). I (We) further agree to reimburse, indemnify, and hold harmless the United States, its agents, servants and

employees from any and all claims or causes of action, including wrongful deaths, that arise or may arise from the acts or omissions that gave

rise to the claim by reason of the same subject matter.

ACCEPTANCE BY CLAIMANT(S)

ACCOUNTING CLASSIFICATION

Date claim accrued , 20

amount of $

(Head of Federal agency, or authorized designee)

, 20

Title

Date

SIGN ORIGINAL ONLY

Pursuant to the authority vested in me, I certify that this voucher is

correct and proper for payment in the

amount of $

(Authorized certifying officer)