GSA Form SF-1147 Request for Issuance of Replacement Check Due to Error in Name and/Or Designation of Payee

GSA Form STANDARD1147 is a U.S. General Services Administration form also known as the "Request For Issuance Of Replacement Check Due To Error In Name And/or Designation Of Payee". The latest edition of the form was released in May 1, 1995 and is available for digital filing.

Download a PDF version of the GSA Form STANDARD1147 down below or find it on U.S. General Services Administration Forms website.

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REQUEST FOR ISSUANCE OF REPLACEMENT CHECK DUE TO ERROR IN NAME AND/OR DESIGNATION OF PAYEE
To Disbursing Office
Date
CHECK NO.
DATE
AMOUNT
SYMBOL NO.
VOUCHER NO.
NAME AND/OR DESIGNATION ON CHECK:
I certify that the correct name and/or
CORRECT NAME AND/OR DESIGNATION:
ADMINISTRATIVE OFFICE
designation of the payee is as shown
hereon and the amount stated is due the
LOCATION
payee. Issuance of a replacement check as
indicated, for delivery in the usual manner,
is authorized.
SIGNATURE OF AUTHORIZED
CERTIFYING OFFICER
Replacement check issued as authorized
Standard Form 1147
Rev. 5/1995
Control No.
Department of the Treasury
I TFRM 4-6000
NAME OF AUTHORIZED CERTIFYING
Previous edition is not usable
OFFICER (Type or print)
Date
For Disbursing Officer
REQUEST FOR ISSUANCE OF REPLACEMENT CHECK DUE TO ERROR IN NAME AND/OR DESIGNATION OF PAYEE
To Disbursing Office
Date
CHECK NO.
DATE
AMOUNT
SYMBOL NO.
VOUCHER NO.
NAME AND/OR DESIGNATION ON CHECK:
I certify that the correct name and/or
CORRECT NAME AND/OR DESIGNATION:
ADMINISTRATIVE OFFICE
designation of the payee is as shown
hereon and the amount stated is due the
LOCATION
payee. Issuance of a replacement check as
indicated, for delivery in the usual manner,
is authorized.
SIGNATURE OF AUTHORIZED
CERTIFYING OFFICER
Replacement check issued as authorized
Standard Form 1147
Rev. 5/1995
Control No.
Department of the Treasury
I TFRM 4-6000
NAME OF AUTHORIZED CERTIFYING
Previous edition is not usable
OFFICER (Type or print)
Date
For Disbursing Officer

Download GSA Form SF-1147 Request for Issuance of Replacement Check Due to Error in Name and/Or Designation of Payee

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