Fillable Acctauth FSF5444 (Department of the Treasury - BPD)

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Acctauth FSF5444 (Department of the Treasury - BPD)

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FS Form 5444 Department of the Treasury | Bureau of the Fiscal Service 1
FS Form 5444 (Revised June 2020) OMB No. 1530-0138
TreasuryDirect® Account Authorization
I
MPORTANT: Follow instructions in filling out this form. Making any false, fictitious, or fraudulent claim or statement to the United States is a crime and
may be prosecuted. Print in ink or type all information.
INSTRUCTIONS
1. Sign in ink in the presence of a certifying officer. Identification may be required.
2. Authorized certifying officers are available at financial institutions, including credit unions, in the United States. Certification by a
notary isn’t acceptable.
3. Mail the completed authorization form to: Treasury Retail Securities Services, PO Box 7015, Minneapolis, MN 55480-7015.
AUTHORIZATION
I submit this account authorization pursuant to the provisions of 31 CFR Part 363. I understand that my TreasuryDirect account will be activated
upon receipt and approval of this authorization. Under penalty of perjury, I certify the information provided is true, correct and complete.
Check to remove Hardlock
Instructions to Certifying Officer: 1. Name(s) of the person(s) who appeared and date of appearance MUST be completed.
2. Original signature is required if a Medallion stamp is used. 3. Person(s) must sign in your presence.
I CERTIFY that ________________________________________________________________________ , whose identity(ies)
(Names of Persons Who Appeared)
is/are known or proven to me, personally appeared before me this _______________ day of _______________ __________
(Month) (Year)
at ___________________________________________________ and signed this form.
(City, State)
__________________
______________________________________
(Signature and Title of Certifying Officer)
________________________________________________________
(Name of Financial Institution)
__________________
______________________________________
(Address)
__________________
______________________________________
(City, State, ZIP code)
__________________
______________________________________ SEE PAGE 2 FOR TYPES OF ACCEPTABLE CERTIFICATIONS
(Telephone)
_______________________________________________________________ ____________________________________
(TreasuryDirect Account Number)
_____________________________________________________ ______________________________________________
(Print Name) (Social Security Number - REQUIRED)
Home Address ________________________________________ ______________________________________________
(Number and Street or Rural Route) (Daytime Telephone Number)
_____________________________________________________ ______________________________________________
(City) (State) (ZIP Code) (E-mail Address)
(Signature)
RESET
For official use only: Customer Name
Case or SR#
Customer No
FS Form 5444 Department of the Treasury | Bureau of the Fiscal Service 2
Acceptable seals and stamps:
•
The financial institution’s official seal or stamp, including: Signature Guaranteed seal or stamp; Endorsement
Guaranteed seal or stamp; Corporate seal or stamp (a corporate resolution isn’t required); or Issuing or paying age
nt
seal or stamp (including name, location, and four-digit identification number or nine-digit routing number).
• The seal or stamp of Treasury-recognized Signature Guarantee Programs or other Treasury-
approved Medallion
Programs.
certification for a financial institution:
Acceptable certification for a brokerage:
SIGNATURE GUARANTEED
ABC National Bank
Hillview Branch
SIGNATURE GUARANTEED
MEDALLION GUARANTEED
Generic Brokerage
Authorized Signature Authorized Signature
XXXXXXXX
SECURITIES TRANSFER AGENTS MEDALLION PROGRAM
[Bar Code]
The following are NOT acceptable forms of certification for this document:
• Notary Certification
• Bank Address stamp
• Signature Validation stamp
NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
The collection of the information you are requested to provide on this form is authorized by 31 U.S.C. CH. 31 relating to the public debt of
the United States. The furnishing of a Social Security Number, if requested, is also required by Section 6109 of the Internal Revenue
Code (26 U.S.C. 6109).
The purpose of requesting the information is to enable the Bureau of the Fiscal Service and its agents to issue securities, process
transactions, make payments, identify owners and their accounts, and provide reports to the Internal Revenue Service. Furnishing the
information is voluntary; however, without the information, the Fiscal Service may be unable to process transactions.
Information concerning securities holdings and transactions is considered confidential under Treasury regulations (31 CFR, Part 323) and
the Privacy Act. This information may be disclosed to a law enforcement agency for investigation purposes; courts and counsel for
litigation purposes; others entitled to distribution or payment; agents and contractors to administer the public debt; agencies or entities for
debt collection or to obtain current addresses for payment; agencies through approved computer matches; Congressional offices in
response to an inquiry by the individual to whom the record pertains; as otherwise authorized by law or regulation.
We estimate it will take you about 5 minutes to complete this form. However, you are not required to provide information requested
unless a valid OMB control number is displayed on the form. Any comments or suggestions regarding this form should be sent to the
Bureau of the Fiscal Service, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form to this
address; send to the correct address shown in the INSTRUCTIONS above.
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Acctauth FSF5444 (Department of the Treasury - BPD)

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Completed 16 July 2020

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