Fill - Disposition of Treasury Securities Belonging to a Decedents (Department of the Treasury

FS Form 5336 Department of the Treasury | Bureau of the Fiscal Service 1

OMB No. 1530-0055 FS Form 5336 (Revised February 2021)

Disposition of Treasury Securities Belonging to a

Decedent’s Estate Being Settled Without Administration

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.

A person applying to act as voluntary representative of a decedent’s estate that is not being administered uses this form 1) to apply to act

as voluntary representative, and 2) to request disposition of United States Treasury Securities and/or related payments belonging to the

estate. See the instructions for the definition of a voluntary representative.

• ALL securities belonging to the decedent’s estate must be included in this transaction.

• If the decedent’s securities and/or related payments are worth over $100,000 redemption and/or par value as of the date of death,

Treasury regulations require that the estate be administered through the court; in that event, this form may not be used.

• We will recognize only ONE voluntary representative to act at any time on behalf of the decedent's estate.

• You cannot use this form to distribute bonds or to make payment to a trust.

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 – ESTATE 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 person named on the securities, name of person who died last)

___________________________________________________ ____________________________________________

(Decedent’s Social Security Number) (State, District or Territory of Legal Residence)

By signing this form, I certify that a legal representative has not been and will not be appointed through the court and that the estate will

not be settled in accordance with the law of the decedent’s domicile (such as Summary Administration, Small Estates Act, Texas

Muniment of Title, Louisiana Judgment of Possession, etc.)

If the above statement does not apply, do not complete this form. Instead, send the securities and all evidence and/or documentation

concerning the estate to the appropriate address in “WHERE TO SEND,” near the end of this form.

PART B – PERSON QUALIFIED TO ACT AS VOLUNTARY REPRESENTATIVE

Title 31, Code of Federal Regulations (CFR), provides that to be qualified to act as voluntary representative, a person must be competent

and eighteen years of age or older and be eligible according to the Order of Precedence for Voluntary Representative shown below.

Carefully read the instructions before completing this Part. Only a blood relative, legally adopted child, or surviving spouse of the

decedent can complete and submit this form. See Instructions at the end of the form for more information.

Mark the box that represents your eligibility to act as voluntary representative.

Order of Precedence for Voluntary Representative

I am the surviving spouse

I am a child of the decedent and there is no competent surviving spouse

I am a descendant of a deceased child of the decedent and there are none of the above who are competent

I am a parent of the decedent and there are none of the above who are competent

I am a brother or sister of the decedent and there are none of the above who are competent

I am a descendant of a deceased brother or sister of the decedent and there are none of the above who are competent

I am next of kin of the decedent as determined by the law of the jurisdiction in which the decedent was domiciled at the

date of death, and there are none of the above who are competent. My relationship to the decedent is

_____________________________________________________________________________________________________.

RESET

For official use only: Customer Name

Case or SR#

Customer No

FS Form 5336 Department of the Treasury | Bureau of the Fiscal Service 2

PART C – TYPE OF DISPOSITION

Title 31, Code of Federal Regulations (CFR), provides that as voluntary representative, you may make a request from the following (mark

the appropriate box or boxes):

Payment to myself as voluntary representative on behalf of all persons entitled to share in the decedent’s estate (except for

unmatured marketable securities). (Continue to Part D. or check the next box also if unmatured marketable securities are

included.)

Transfer of unmatured marketable securities to a financial institution, broker, or dealer account in MY name to be sold on behalf of

all persons entitled. (Check the previous box also if savings bonds and/or matured marketable securities are included.) (Skip to

Part E.)

Distribution of securities and/or related payments to the persons entitled according to the law of the jurisdiction in which the decedent

was domiciled at the date of death. (If this box is checked, the other two cannot be checked.) (Skip to Part F.)

PART D – PAYMENT TO VOLUNTARY REPRESENTATIVE

I request that payment of the savings bonds or matured Treasury bills, notes, bonds, TIPS or Floating Rate Notes and/or related

payments be made to me as voluntary representative. (If you have unmatured marketable securities, use Part E.)

1. Pay to: ___________________________________________________________ ____________________________________

(Name) (Social Security Number)

___________________________________________________________ ____________________________________

(Mailing Address) (E-Mail Address)

2. Description of securities and/or related payments (If you need more space, attach either a list or FS Form 3500

(see www.treasurydirect.gov/forms/sav3500.pdf):

TITLE OF SECURITY

(See page 7 for examples)

ISSUE

DATE

FACE AMOUNT IDENTIFYING NUMBER REGISTRATION

3. Payment information

Payment for savings bonds (paper or electronic) and matured electronic marketable securities will be made by direct deposit. Below,

please identify the account where you want your payment for these securities.

For information on payment of paper marketable securities, see the Instructions.

________________________________________________________________________________________

(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.)

(If you completed Part D to receive payment as voluntary representative, only complete Part E if unmatured marketable securities are

included. Skip Part F, and sign in Part G.)

PART E – TRANSFER TO VOLUNTARY REPRESENTATIVE

Transfer all unmatured marketable securities in the below account(s) to a financial institution, broker, or dealer account in MY name to be

sold on behalf of all persons entitled.

1. Transfer to: _______________________________________________________ __________________________________

(Name) (Social Security Number)

_______________________________________________________________________________________________

(Mailing Address)

FS Form 5336 Department of the Treasury | Bureau of the Fiscal Service 3

2. Securities identification:

Account number(s): _______________________________________________________________________________

3. External transfer to a financial institution

NOTE: Failure to provide any of the following information could delay the transfer. See instructions before completing.

Routing Number (nine digits, and begins with 0, 1, 2, or 3): _________________________________

Financial Institution Wire Name: ___________________________________________________________________________________

Agent or Broker Name: _______________________________________ Agent or Broker Phone Number: ________________________

Agent or Broker Address: ________________________________________________________________________________________

Special Handling Instructions: _____________________________________________________________________________________

_____________________________________________________________________________________________________________

(If you completed Part E to transfer as voluntary representative, only complete Part D if matured marketable securities and/or

savings bonds are also included. Skip Part F, and sign in Part G.)

PART F – DISTRIBUTION OF SECURITIES AND/OR RELATED PAYMENTS TO PERSON ENTITLED

If a person entitled to paper savings bonds (Series EE, E, I, HH, or H) wants:

• payment, he or she must submit FS Form 1522

• reissue to himself or herself, he or she must submit FS Form 4000

• reissue to a trust, he or she must submit FS Form 1851

A person entitled to electronic securities held in TreasuryDirect must submit FS Form 5511 for transfer or FS Form 5512

for redemption.

For forms, go to www.treasurydirect.gov

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

I request that the securities and/or related payments be distributed as follows:

1. Distribute to: ______________________________________________________________________________________________

(Name of first distributee)

_____________________________________________________ ____________________________________________

(Social Security Number) (Telephone Number)

_____________________________________________________ ____________________________________________

(Address) (E-mail Address)

2. Description of securities and/or related payments to go to the first distribute (If you need more space, attach

either a list or FS Form 3500 (see www.treasurydirect.gov/forms/sav3500.pdf):

TITLE OF SECURITY

(See page 7 for examples)

ISSUE

DATE

FACE AMOUNT IDENTIFYING NUMBER 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. Marketable securities may be distributed in full or in increments of $100. Savings bonds issued in electronic form

must be at least $25.

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

_____________________________________________________________________________________________________________

FS Form 5336 Department of the Treasury | Bureau of the Fiscal Service 4

PART F – DISTRIBUTION OF SECURITIES AND/OR RELATED PAYMENTS TO PERSON ENTITLED (Continued)

I request that the securities and/or related payments be distributed as follows:

1. Distribute to: ______________________________________________________________________________________________

(Name of second distributee)

_____________________________________________________ ____________________________________________

(Social Security Number) (Telephone Number)

_____________________________________________________ ____________________________________________

(Address) (E-mail Address)

2. Description of securities and/or related payments to go to the second distribute (If you need more space, attach

either a list or FS Form 3500 (see www.treasurydirect.gov/forms/sav3500.pdf):

TITLE OF SECURITY

(See page 7 for examples)

ISSUE

DATE

FACE AMOUNT IDENTIFYING NUMBER 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. Marketable securities may be distributed in full or in increments of $100. Savings bonds issued in electronic form

must be at least $25.

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

_____________________________________________________________________________________________________________

========================================================================================================

I request that the securities and/or related payments be distributed as follows:

1. Distribute to: ______________________________________________________________________________________________

(Name of third distributee)

_____________________________________________________ ____________________________________________

(Social Security Number) (Telephone Number)

_____________________________________________________ ____________________________________________

(Address) (E-mail Address)

2. Description of securities and/or related payments to go to the third distribute (If you need more space, attach

either a list or FS Form 3500 (see www.treasurydirect.gov/forms/sav3500.pdf):

TITLE OF SECURITY

(See page 7 for examples)

ISSUE

DATE

FACE AMOUNT IDENTIFYING NUMBER 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. Marketable securities may be distributed in full or in increments of $100. Savings bonds issued in electronic form

must be at least $25.

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

_____________________________________________________________________________________________________________

FS Form 5336 Department of the Treasury | Bureau of the Fiscal Service 5

PART G – SIGNATURE AND CERTIFICATION

I certify under penalty of perjury that the information provided herein is true and correct to the best of my knowledge and belief and that I

am eligible to act as voluntary representative. I further certify that I will distribute payment made to me as voluntary representative or that I

am distributing the securities and/or related payments to the persons entitled by the law of the jurisdiction in which the decedent was

domiciled at the date of death. The United States is not liable to any person for the improper distribution of payments or securities. Upon

payment or distribution of the securities at my request as voluntary representative, the United States is released to the same extent as if it

had paid or delivered to a representative of the estate appointed pursuant to the law of the jurisdiction in which the decedent was

domiciled at the date of death.

I bind myself, my 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. I 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.

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)

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)

(Applicant’s Signature, as Voluntary Representative of the Decedent’s Estate)

FS Form 5336 Department of the Treasury | Bureau of the Fiscal Service 6

INSTRUCTIONS

USE OF FORM – A voluntary representative is a person qualified by the Department of the Treasury 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 (not exceeding $100,000) that belong to a decedent’s estate if the estate is not being administered through the court. A

voluntary representative of the decedent’s estate must complete this form to request:

• Payment on behalf of persons entitled to the estate according to the law of the jurisdiction in which the decedent was domiciled

at the date of death.

• Transfer of unmatured marketable securities to a financial institution, broker, or dealer account in the voluntary representative’s

name to be sold on behalf of all persons entitled.

• Distribution of the securities to the persons entitled to the estate according to the law of the jurisdiction in which the decedent

was domiciled at the date of death.

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 – ESTATE 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. Submit certified copies of the death certificates for all deceased registrants.

Insert the following information:

• Decedent’s name.

• Decedent’s Social Security Number.

• Jurisdiction (state, district, or territory) of decedent’s last legal residence.

By signing this form you certify that the decedent’s estate has not been and will not be administered through a court or settled in

accordance with the law of the decedent’s domicile (such as Summary Administration, Small Estates Act, Texas Muniment of Title,

Louisiana Judgment of Possession, etc.). If a legal representative has been appointed by the court, if the estate has been

administered and is now closed, or if you have a document establishing entitlement to the estate (other than an unprobated

will), do not complete this form. Instead, send the securities and all evidence and/or documentation concerning the estate to the

appropriate address in “WHERE TO SEND,” near the end of this form. Upon review of the submission, we will provide additional

instructions, if necessary.

PART B – PERSON QUALIFIED TO ACT AS VOLUNTARY REPRESENTATIVE

Starting at the top, read down the Order of Precedence until you find the situation that applies to you. Mark the box that represents your

eligibility to act as voluntary representative. (If the last box is marked, show your relationship to the decedent.) For example, if the

decedent leaves a competent surviving spouse and children (over the age of eighteen), the competent surviving spouse must complete

this form. If there is no competent surviving spouse, one of the children (over the age of eighteen) must complete this form.

NOTE: Only a blood relative, legally adopted child, or surviving spouse of the decedent can complete and submit this form. This restriction

applies even to a person acting as an attorney-in-fact. The estate may need to be settled in accordance with the laws of the decedent’s

domicile (such as Summary Administration, Small Estates Act, Texas Muniment of Title, Louisiana Judgment of Possession, etc.)

NOTE: This form cannot be used to distribute bonds to a trust or to make payment to a trust.

PART C – TYPE OF DISPOSITION

Mark the appropriate box. If you are requesting payment, continue to Part D. If you are requesting distribution, skip Part D.

PART D – PAYMENT TO VOLUNTARY REPRESENTATIVE

Complete this part to receive payment as voluntary representative for savings bonds or matured marketable securities.

A person acting as voluntary representative who receives payment of securities and/or related payments warrants, certifies, and

unconditionally guarantees that he or she will make distribution of the proceeds to the persons entitled by the law of the decedent's

domicile at the date of death. Payment to a voluntary representative is for the convenience of the United States and does not determine

ownership of the securities or their proceeds.

1. Provide your name, Social Security Number, and mailing address.

Note: Your Social Security Number may be used to report all of the interest earned to the Internal Revenue Service for Federal income

tax purposes. For Federal income tax information, see IRS Publication 550 or contact the IRS or your tax advisor.

2. Describe the securities and/or checks:

• TITLE OF SECURITY – Identify each security by series, interest rate, type, CUSIP, and 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.

FS Form 5336 Department of the Treasury | Bureau of the Fiscal Service 7

• 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. XXX-XX-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.

3. Payment for savings bonds (paper or electronic) and matured electronic marketable securities will be made by direct deposit. To

receive payment for these securities, please provide the requested information. If you don’t know the routing number of your financial

institution, the financial institution can give it to you.

Payment for paper marketable securities will be made by check. (This does NOT include savings bonds. Payment for savings bonds will

be made by direct deposit.)

If you completed Part D to receive payment as voluntary representative, only complete Part E if unmatured marketable securities are

included. Skip Part F, and sign in Part G.

PART E – TRANSFER TO VOLUNTARY REPRESENTATIVE

Complete this part to transfer the unmatured marketable securities to a financial institution, broker, or dealer account in YOUR

name to receive payment on behalf of all persons entitled.

A person acting as voluntary representative who transfers securities warrants, certifies, and unconditionally guarantees that he/she will

make distribution of the proceeds to the persons entitled by the law of the decedent's domicile at the date of death. Transfer to a voluntary

representative is for the convenience of the United States and does not determine ownership of the securities or their proceeds.

IMPORTANT NOTICES

• All scheduled reinvestments will be cancelled at the time of transfer.

• This form must be signed. Only original signatures and forms will be accepted (stamped signatures are not acceptable).

• TRANSFER REQUESTS WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS.

1. Provide your name and mailing address.

2. Securities Identification

Provide the information requested. All required information is listed on the Legacy Treasury Direct statement of account or in the

TreasuryDirect account of the decedent.

3. External transfer to a financial institution that accepts wire transfers.

Contact the financial institution for its "Book-Entry" delivery instructions. Please note: Securities CANNOT be transferred to a

checking or savings account since they can only accept money. Provide the following information:

ROUTING NUMBER - ABA (identification) number of the financial institution receiving the securities.

FINANCIAL INSTITUTION WIRE NAME - Provide the financial institution's "Book-Entry" delivery instructions. Instructions

include the receiving bank's name and the brokerage firm's name (these must be approved telegraphic abbreviation "short"

form).

AGENT or BROKER NAME, PHONE NUMBER, ADDRESS

SPECIAL HANDLING INSTRUCTIONS - The voluntary representative’s name and account number at the financial institution for

delivery of securities; and other instructions required by your financial institution.

Examples:

To a financial institution for safekeeping: To a financial institution for transfer to brokerage firm:

Routing Number: XXXXXXXXX Routing Number: XXXXXXXXX

Financial Institution Wire Name: ABC BK/TRUST Financial Institution Wire Name: ABC/CUST/BRKG

Special Handling Instructions: FURTHER CREDIT TO JOHN DOE Special Handling Instructions: FURTHER CREDIT TO JOHN DOE

TRUST ACCOUNT NUMBER XXXXXX

BROKERAGE ACCOUNT NUMBER XXXXXX

CONFIRMATION OF THE TRANSFER

Legacy Treasury Direct: You will receive a Statement of Account after the securities have been transferred. Under certain circumstances,

there may be a hold on the account and a statement won't be mailed.

FS Form 5336 Department of the Treasury | Bureau of the Fiscal Service 8

If you completed Part E to transfer as voluntary representative, only complete Part D if matured marketable securities and/or savings

bonds are also included. Skip Part F, and sign in Part G.

PART F – DISTRIBUTION OF SECURITIES AND/OR RELATED PAYMENTS TO PERSON ENTITLED

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

A person acting as voluntary representative who distributes securities and/or related payments warrants, certifies, and unconditionally

guarantees that he or she is making distribution to the persons entitled by the law of the decedent's domicile at the date of death.

1. Enter the name, Social Security Number, address, and phone number of only one distributee in each Part F, Item 1. (Complete a

separate Part F for each distributee.)

2. Describe only the securities and/or checks that the person shown in Item 1 is to receive. In the instructions, see Item 2 in Part D for

information on how to describe securities and/or checks.

In all cases, we need an additional form or forms from the distributee as indicated in Part F. Our forms may be downloaded at

www.treasurydirect.gov.

If an entitled person wants payment of paper marketable securities not held electronically, the fiduciary must complete the

assignment on the reverse of the security. The distributee must complete IRS Form W-9.

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

are distributed, unless otherwise requested.

PART G – SIGNATURES AND CERTIFICATIONS

SIGNATURES – Application must be signed in ink.

CERTIFICATION – You must appear before and establish identification to the satisfaction of an authorized certifying officer. The form

must be signed in the officer’s presence. The certifying officer must affix the seal or stamp that is used when certifying requests for

payment. Authorized certifying officers are available at most financial 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 REQUIREMENTS – 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 and/or the formal administration of the estate.

WHERE TO SEND – Unless otherwise instructed in accompanying correspondence, mail this form (without instruction pages), mail all

securities and/or related checks, and mail any necessary evidence to the appropriate address. Legal evidence or documentation you

submit cannot be returned.

• For Series HH or Series H savings bonds – Treasury Retail Securities Services, PO Box 2186, Minneapolis, MN 55480-2186.

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

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

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

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

Note: Use only one form and describe all the securities.

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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