Fill - Agreement and Request for Disposition of a Decedents (Department of the Treasury

FS Form 5394 Department of the Treasury | Bureau of the Fiscal Service 1

FS Form 5394 (Revised June 2020) OMB No. 1530-0046

Agreement and Request for Disposition

of a Decedent’s Treasury Securities

IMPORTANT: 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.

USE OF FORM – Use this form to request disposition of United States Treasury Securities (Treasury Bills, Notes, Bonds, TIPS, Floating

Rate Notes, Savings Bonds, and Savings Notes) and/or related payments belonging to a decedent’s estate, but only under one of the

circumstances described in the instructions.

NOTE: When we reissue a Series EE or Series I savings bond, we no longer provide a paper bond. The reissued bond is in electronic

form, in our online system TreasuryDirect. For information on opening an account in TreasuryDirect, go to www.treasurydirect.gov.

PART A – DECEDENT’S INFORMATION

Provide the information below and submit certified copies of the death certificates for all deceased registrants.

________________________________________________________________________________________________

(NAME OF DECEASED OWNER – If more than one, name of person who died last)

_______________________________________ _______________________________________

(Social Security Number of person named above) (State of legal residence of person named above)

PART B- CIRCUMSTANCES OF REQUEST

Mark the appropriate box to indicate the circumstances under which you are using this form. See Part B of the instructions

for evidence requirements.

1. This request is made in connection with an estate that has been administered, the legal representative discharged, and the estate

closed. Evidence – a certified copy of the final account or decree of distribution.

2. This request is made in connection with an estate that is being settled in accordance with State statute (for example: Summary

Administration, Small Estates Act, Texas Muniment of Title, or Louisiana Judgment of Possession). Evidence – Submit

evidence in accordance with state law or statute.

PART C – PERSONS ENTITLED

1. List all persons entitled to the securities and/or payments (according to the supporting evidence):

Name Basis of Entitlement

Age

(if under 21)

2. List all persons from Item 1 who are under legal disability (if any):

Name

Legal Disability

Name and Address of Representative

Capacity

RESET

For official use only: Customer Name

Case or SR#

Customer No

FS Form 5394 Department of the Treasury | Bureau of the Fiscal Service 2

PART D – DISPOSITION OF SECURITIES AND PAYMENT TO PERSONS ENTITLED - Complete a separate Part D for each entitled

person.

We, the person(s) entitled to the decedent’s estate, request and agree to distribution of the decedent's securities and/or

payments as follows:

1. Distribute to:

_____________________________________________________ _____________________________________________

(Name of Entitled Person) (Social Security Number OR Employer Identification Number)

2. Description of securities and/or payments:

TITLE OF SECURITY

(See page 8 for examples)

ISSUE

DATE

FACE AMOUNT IDENTIFYING NUMBER REGISTRATION

NOTE: Individual savings bonds may not be split. Each savings bond must be distributed, in its entirety, to an entitled individual or

entity. Marketable securities may be distributed in full or in increments of $100.

If you want to split a marketable security, describe the exact amount of the distribution: ________________________________________

3. Type of distribution:

NOTE: Choose the option for the particular type of security involved; securities can’t be transferred from one series or term to another.

Complete a separate Part D (see following pages) for each different registration or type of distribution desired.

Savings Bonds or Notes (paper)

(Series A-D, E, F, G, H, HH, J, K)

Payment (must be by direct deposit)

Series HH Savings Bonds (paper)

Reissue in single-owner form

Reissue with a coowner *

Reissue with a beneficiary *

Note: Savings bonds within one month of final

maturity cannot be reissued.

* Name of coowner or beneficiary

______________________________________

Savings Bonds (paper & electronic)

(Series EE and Series I)

Payment (Must be by direct deposit)

Reissue to TreasuryDirect® Account Number _________________________

Transfer to TreasuryDirect Account Number ___________________________

NOTE: Savings bonds within one month of final maturity cannot be reissued.

Treasury Bills, Notes, Bonds, TIPS, FRNs (paper or electronic)

Transfer unmatured securities to this TreasuryDirect or *Legacy Treasury

Direct account number: ____________________________

Transfer unmatured securities to a financial institution, broker, or dealer.

*Payment of the matured paper security – by check (not for savings bonds)

Payment of the matured electronic security – by direct deposit

*NOT available for FRNs

4. Mailing address: ____________________________________________________________________________________________

5. E-mail address: _____________________________________________________________________________________________

6. Direct-deposit funds as authorized below:

________________________________________________________________________________________

(Name/Names on the Account)

Bank Routing No. (nine digits, and begins with 0, 1, 2, or 3): _______________________________

_________________________________________ Type of Account Checking Savings

(Depositor’s Account No.)

___________________________________________________ ______________________________

(Financial Institution’s Name) (Financial Institution’s Phone No.)

FS Form 5394 Department of the Treasury | Bureau of the Fiscal Service 3

PART D – DISPOSITION OF SECURITIES AND PAYMENT TO PERSONS ENTITLED (Continued)

1. Distribute to:

_____________________________________________________ _____________________________________________

(Name of Entitled Person) (Social Security Number OR Employer Identification Number)

2. Description of securities and/or payments:

TITLE OF SECURITY

(See page 8 for examples)

ISSUE

DATE

FACE AMOUNT IDENTIFYING NUMBER REGISTRATION

NOTE: Individual savings bonds may not be split. Each savings bond must be distributed, in its entirety, to an entitled individual or

entity. Marketable securities may be distributed in full or in increments of $100.

If you want to split a marketable security, describe the exact amount of the distribution: ________________________________________

3. Type of distribution:

NOTE: Choose the option for the particular type of security involved; securities can’t be transferred from one series or term to another.

Complete a separate Part D (see following pages) for each different registration or type of distribution desired.

Savings Bonds or Notes (paper)

(Series A-D, E, F, G, H, HH, J, K)

Payment (must be by direct deposit)

Series HH Savings Bonds (paper)

Reissue in single-owner form

Reissue with a coowner *

Reissue with a beneficiary *

Note: Savings bonds within one month of final

maturity cannot be reissued.

* Name of coowner or beneficiary

______________________________________

Savings Bonds (paper & electronic)

(Series EE and Series I)

Payment (Must be by direct deposit)

Reissue to TreasuryDirect® Account Number _________________________

Transfer to TreasuryDirect Account Number ___________________________

NOTE: Savings bonds within one month of final maturity cannot be reissued.

Treasury Bills, Notes, Bonds, TIPS, FRNs (paper or electronic)

Transfer unmatured securities to this TreasuryDirect or *Legacy Treasury

Direct account number: ____________________________

Transfer unmatured securities to a financial institution, broker, or dealer.

*Payment of the matured paper security – by check (not for savings bonds)

Payment of the matured electronic security – by direct deposit

*NOT available for FRNs

4. Mailing address: ____________________________________________________________________________________________

5. E-mail address: _____________________________________________________________________________________________

6. Direct-deposit funds as authorized below:

________________________________________________________________________________________

(Name/Names on the Account)

Bank Routing No. (nine digits, and begins with 0, 1, 2, or 3): _______________________________

_________________________________________ Type of Account Checking Savings

(Depositor’s Account No.)

___________________________________________________ ______________________________

(Financial Institution’s Name) (Financial Institution’s Phone No.)

FS Form 5394 Department of the Treasury | Bureau of the Fiscal Service 4

PART D – DISPOSITION OF SECURITIES AND PAYMENT TO PERSONS ENTITLED (Continued)

1. Distribute to:

_____________________________________________________ _____________________________________________

(Name of Entitled Person) (Social Security Number OR Employer Identification Number)

2. Description of securities and/or payments:

TITLE OF SECURITY

(See page 8 for examples)

ISSUE

DATE

FACE AMOUNT IDENTIFYING NUMBER REGISTRATION

NOTE: Individual savings bonds may not be split. Each savings bond must be distributed, in its entirety, to an entitled individual or

entity. Marketable securities may be distributed in full or in increments of $100.

If you want to split a marketable security, describe the exact amount of the distribution: ________________________________________

3. Type of distribution:

NOTE: Choose the option for the particular type of security involved; securities can’t be transferred from one series or term to another.

Complete a separate Part D (see following pages) for each different registration or type of distribution desired.

Savings Bonds or Notes (paper)

(Series A-D, E, F, G, H, HH, J, K)

Payment (must be by direct deposit)

Series HH Savings Bonds (paper)

Reissue in single-owner form

Reissue with a coowner *

Reissue with a beneficiary *

Note: Savings bonds within one month of final

maturity cannot be reissued.

* Name of coowner or beneficiary

______________________________________

Savings Bonds (paper & electronic)

(Series EE and Series I)

Payment (Must be by direct deposit)

Reissue to TreasuryDirect® Account Number _________________________

Transfer to TreasuryDirect Account Number ___________________________

NOTE: Savings bonds within one month of final maturity cannot be reissued.

Treasury Bills, Notes, Bonds, TIPS, FRNs (paper or electronic)

Transfer unmatured securities to this TreasuryDirect or *Legacy Treasury

Direct account number: ____________________________

Transfer unmatured securities to a financial institution, broker, or dealer.

*Payment of the matured paper security – by check (not for savings bonds)

Payment of the matured electronic security – by direct deposit

*NOT available for FRNs

4. Mailing address: ____________________________________________________________________________________________

5. E-mail address: _____________________________________________________________________________________________

6. Direct-deposit funds as authorized below:

________________________________________________________________________________________

(Name/Names on the Account)

Bank Routing No. (nine digits, and begins with 0, 1, 2, or 3): _______________________________

_________________________________________ Type of Account Checking Savings

(Depositor’s Account No.)

___________________________________________________ ______________________________

(Financial Institution’s Name) (Financial Institution’s Phone No.)

FS Form 5394 Department of the Treasury | Bureau of the Fiscal Service 5

PART E – SIGNATURES AND CERTIFICATIONS

The undersigned certify under penalty of perjury that the information provided herein is true and correct to the best of our

knowledge and belief and agree to distribution of the securities as indicated in Part D. We bind ourselves, our heirs, legatees,

successors and assigns, jointly and severally, to hold the United States harmless on account of the transaction requested, to indemnify

unconditionally and promptly repay the United States in the event of any loss which results from this request, including interest,

administrative costs, and penalties. We consent to the release of any information regarding this transaction, including information

contained in this application, to any party having an ownership or entitlement interest in the securities or payments.

Person to contact if additional information is necessary: ___________________________________________________________

(Name)

_____________________________________ ________________________________________

(

Daytime Phone Number) (E-mail Address)

Sign Here: ______________________________________________________________________________________________

_____________________________________________________ _____________________________________________

(Print Name) (Social Security Number)

Home Address ________________________________________ ______________________________________________

(Number and Street or Rural Route) (Daytime Telephone Number)

_____________________________________________________ ______________________________________________

(City) (State) (ZIP Code) (E-mail Address)

Sign Here: ______________________________________________________________________________________________

_____________________________________________________ _____________________________________________

(Print Name) (Social Security Number)

Home Address ________________________________________ ______________________________________________

(Number and Street or Rural Route) (Daytime Telephone Number)

_____________________________________________________ ______________________________________________

(City) (State) (ZIP Code) (E-mail Address)

Sign Here: ______________________________________________________________________________________________

_____________________________________________________ _____________________________________________

(Print Name) (Social Security Number)

Home Address ________________________________________ ______________________________________________

(Number and Street or Rural Route) (Daytime Telephone Number)

_____________________________________________________ ______________________________________________

(City) (State) (ZIP Code) (E-mail Address)

Sign Here: ______________________________________________________________________________________________

_____________________________________________________ _____________________________________________

(Print Name) (Social Security Number)

Home Address ________________________________________ ______________________________________________

(Number and Street or Rural Route) (Daytime Telephone Number)

_____________________________________________________ ______________________________________________

(City) (State) (ZIP Code) (E-mail Address)

Sign Here: ______________________________________________________________________________________________

_____________________________________________________ _____________________________________________

(Print Name) (Social Security Number)

Home Address ________________________________________ ______________________________________________

(Number and Street or Rural Route) (Daytime Telephone Number)

_____________________________________________________ ______________________________________________

(City) (State) (ZIP Code) (E-mail Address)

(Signature)

Signature

(Signature)

FS Form 5394 Department of the Treasury | Bureau of the Fiscal Service 6

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 INSTRUCTIONS FOR ACCEPTABLE CERTIFICATION

(Telephone)

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 INSTRUCTIONS FOR ACCEPTABLE CERTIFICATION

(Telephone)

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 INSTRUCTIONS FOR ACCEPTABLE CERTIFICATION

(Telephone)

FS Form 5394 Department of the Treasury | Bureau of the Fiscal Service 7

INSTRUCTIONS

USE OF FORM – Use this form to request disposition of United States Treasury Securities (Treasury Bills, Notes, Bonds, TIPS, Floating

Rate Notes, Savings Bonds, and Savings Notes) and/or related payments belonging to a decedent’s estate, under either of the following

circumstances:

•

The estate was formally administered through the court and has been closed.

•

The estate is being settled in accordance with State statute such as Summary Administration, Small Estates Acts, Texas

Muniment of Title, Louisiana Judgment of Possession, etc., without the necessity of the court appointing an administrator,

executor, or similar legal representative.

ATTACHMENTS – If you need more space for any item, use a plain sheet of paper or make a photocopy of the relevant section, and

attach to the form.

PART A – DECEDENT’S INFORMATION

Provide the requested information regarding the decedent. If more than one deceased person is named on the securities, provide

the information for the person who died last.

Insert the following information: the decedent’s name, the decedent’s Social Security Number, the state of the decedent’s last legal

residence.

Submit certified copies of the death certificates for all deceased registrants

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 INSTRUCTIONS FOR ACCEPTABLE CERTIFICATION

(Telephone)

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 INSTRUCTIONS FOR ACCEPTABLE CERTIFICATION

(Telephone)

FS Form 5394 Department of the Treasury | Bureau of the Fiscal Service 8

PART B – CIRCUMSTANCES OF REQUEST

Mark the appropriate box to indicate the circumstances under which you are using this form.

• Mark box 1 if the estate has been settled through court proceedings and the legal representative is no longer acting.

• Mark box 2 if the estate is being settled in accordance with State statute (for example: Summary Administration, Small

Estates Act, Texas Muniment of Title, or Louisiana Judgment of Possession).

Evidence Requirements:

If the estate is closed, submit a certified copy under court seal of the final account or decree of distribution, if any.

If the estate is being settled in accordance with State statute, submit a certified copy (if filed with the court), of the evidence making

distribution of the securities and/or payments or establishing your authority to collect the proceeds of the estate in accordance with the

State law or statute.

PART C – PERSONS ENTITLED

1. List all persons entitled, the basis of their entitlement (i.e., “legatee,” “surviving spouse,” etc.), and ages if under 21.

2. Show any of the persons listed in Item 1 who are under a legal disability. In the space for “Legal Disability,” enter the nature of the

disability, such as the individual is an “incapacitated person.” If the court appointed a legal representative, show the legal

representative’s name and address. In the space for “Capacity,” enter the official title or description of the representative acting; for

example, “legal guardian” or “conservator.” The representative must submit a certified copy under court seal of the letters of

appointment dated within one year of submission.

PART D – DISPOSITION OF SECURITIES AND PAYMENTS TO PERSONS ENTITLED

1. Enter the name of only one entitled person in each Part D, Item 1. (A separate Part D must be completed for each person entitled and

each type of distribution desired.) Enter the appropriate Social Security or Employer Identification Number.

2. Describe only the securities or checks to which the person shown in Item 1 is entitled.

• TITLE OF SECURITY – Identify each security by series, interest rate, type, CUSIP, call and maturity date, as appropriate. If

describing a check, insert the word “check.”

• ISSUE DATE – Provide the issue date of each security or check.

• FACE AMOUNT – Provide the face amount (par or denomination) of each security or check.

• IDENTIFYING NUMBER (if applicable) – Provide the serial number of each security, the confirmation number, or the check

number.

• REGISTRATION – Provide the registration of each security, check, or account; also provide the account number, if any.

Note: If the Taxpayer Identification Number is included in the registration but is masked (i.e. ***-**-1234), please be sure to provide the

entire number.

Examples:

TITLE OF SECURITY

ISSUE

DATE

FACE AMOUNT IDENTIFYING NUMBER REGISTRATION

Paper Marketable Security

9 1/8 % TREASURY BOND OF

2004-2009 MATURES 5/15/09

CUSIP 912810CG1

5/15/79 $5,000

Serial #

123

JOHN DOE AND JANE DOE

SSN 222-22-2222

Electronic Marketable Security

CUSIP 912795QW4

2/5/04 $1,000

ACCT # 4800-123-1234

JOHN DOE

SSN 222-22-2222

Electronic Series I Savings Bond

SERIES I

1/1/02 $100

Confirmation #

IAAAA

ACCT # N-111-111-111

JOHN DOE

Paper Series EE Savings Bond

SERIES EE

7/99 $100

Serial #

C-123,456,789-EE

SSN 222-22-2222

JOHN DOE

OR JANE DOE

Check

CHECK

7/26/04 $351.02

Check #

502123456

JOHN DOE

If unsure what to provide in each of the areas, furnish all identifying information in the space for REGISTRATION.

NOTE: Individual savings bonds (Series EE, E, I, HH, and H) may not be split. Each savings bond must be distributed, in its entirety, to

an entitled individual or entity. Marketable securities may be distributed in full or in increments of $100. If you want to split a marketable

security, describe the exact amount of the distribution

FS Form 5394 Department of the Treasury | Bureau of the Fiscal Service 9

3. Check the appropriate block indicating type of distribution for the particular type of security involved. Securities can’t be transferred

from one series or term to another. Eligible securities can be transferred within Legacy Treasury Direct, but not into Legacy Treasury

Direct from outside Legacy Treasury Direct. Provide account numbers, if any.

• Provide a separate Part D for each different registration or type of distribution desired.

• In certain circumstances, we may need to request additional forms and/or information in order to complete the requested action.

In this event, we will provide any additional forms and/or instructions.

• Reissue or transfer (when applicable) isn't an option if there is not sufficient time to process the transaction before the security

matures. If we are unable to process a reissue or transfer request before the security matures, payment will be issued. All

Savings Bonds of Series A, B, C, D, E, F, G, H, J, and K, and all Savings Notes, have reached final maturity.

• Any interest that is due or becomes due on securities belonging to the estate of the decedent will be paid to the person to whom

the securities are distributed, unless otherwise requested

4. Provide your mailing address.

5. Provide your e-mail address.

6. Provide information on the bank account where the payment is to be direct-deposited. All persons requesting payment must sign in

Part E of this form. If payment is to be deposited to a bank account in the name of a different person, then that person or his or her

representative, who can authorize such a deposit, must also sign in Part E.

PART E – SIGNATURES AND CERTIFICATIONS

SIGNATURES – The application must be signed in ink by:

• All competent persons listed in Part C, Item 1, and Part D, Item 1.

• The legal guardian or similar representative of the estate of any person under legal disability listed in Part C, Item 2, or Part D,

Item 1; and

• A parent on behalf of any minor listed in Part C, Item 1, or Part D, Item 1.

CERTIFICATION – Each person whose signature is required must appear before and establish identification to the satisfaction of an

authorized certifying individual. The signatures to the form must be signed in the certifying individual’s presence. The certifying individual

must affix the seal or stamp which is used when certifying requests for payment. Authorized certifying individuals are available at most

banking institutions, including credit unions. Certification by a notary isn’t acceptable. Examples of 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 agent 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.

ADDITIONAL EVIDENCE – The Commissioner of the Fiscal Service, as designee of the Secretary of the Treasury, reserves the right in

any particular case to require the submission of additional evidence.

WHERE TO SEND – Send this form (without instruction pages), send all securities and/or related checks, and send any necessary

evidence to the Treasury Retail Securities Site, using the appropriate address below. Legal evidence or documentation you submit

cannot be returned.

• HH and H savings bonds – Treasury Retail Securities Services, PO Box 2186, Minneapolis, MN 55480-2186

• Other paper savings bonds – Treasury Retail Securities Services, PO Box 214, Minneapolis, MN 55480-0214

• Securities in TreasuryDirect – Treasury Retail Securities Services, PO Box 7015, Minneapolis, MN 55480-7015

• Securities in Legacy Treasury Direct – Treasury Retail Securities Services, PO Box 9150, Minneapolis, MN 55480-9150

• Paper marketable securities – Treasury Retail Securities Services, PO Box 9150, Minneapolis, MN 55480-9150

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 30 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 the completed form to this

address; send it to the correct address shown in "WHERE TO SEND.”

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