Fillable INDEMNIFICATION STATEMENT FORM 700-A (Department of the Treasury - BPD)

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INDEMNIFICATION STATEMENT FORM 700-A (Department of the Treasury - BPD)

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INDEMNIFICATION STATEMENT FORM 700-A
This is a facsimile of an original United States Savings Bond/Note containing the following data.
SERIAL NUMBER ISSUE DATE
(Month/Year)
PAYMENT DATE
(Month/Year)
PAYMENT AMOUNT
The bond/note has been endorsed by the undersigned and reported missing or destroyed while in
the regular course of bank collection. The undersigned guarantees the validity of this facsimile
and all prior or any missing endorsements and agrees to be bound by the regulations contained in
Treasury Circular No. 750, current revision (31 CFR Part 321), for any loss sustained by the
Treasury or an endorsing bank in honoring this facsimile.
Reason for Facsimile:
Institution Name and Address:
Routing and Transit # (ABA #) of Institution:
Authorized Signature:
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INDEMNIFICATION STATEMENT FORM 700-A (Department of the Treasury - BPD)

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Completed 28 July 2021

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