Fillable Sav1050 FS Form 1050

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Sav1050 FS Form 1050

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For official use only:
Customer Name
Case Number
OMB No. 1530-0027
FS Form 1050 (Revised March 2018)
Creditor’s Request for Payment of Treasury
Securities Belonging to a Decedent’s Estate
Being Settled Without Administration
IMPORTANT: Follow instructions in filling out this form. You should be aware that the making of any false, fictitious, or fraudulent claim or
statement to the United States is a crime that is punishable by fine and/or imprisonment.
PRINT IN INK OR TYPE ALL INFORMATION
An unpaid creditor must complete this form to request payment of United States Securities and/or related payments belonging to a
decedent’s estate that is not being administered. See the instructions for additional information.
Carefully read the instructions before completing this form.
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, the person who died last)
(Jurisdiction of Legal Residence)
By signing this form, I certify that I have read the instructions for the use of this form and I am entitled to make this claim.
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 address shown in “WHERE TO SEND.”
PART B – PAYMENT TO CREDITOR
Provide the information below and submit any supporting documentation (e.g. receipts, statements, invoices).
1. Amount Owed: $____________ 2. Nature of Claim: _______________________________________________________________
3. I hereby certify that the amount owed has not been paid and is still justly due and owing to the below-
named creditor. I further certify
that the debt has not been barred by any applicable law. I request payment of United
States Treasury securities and/or related payments
belonging to the decedent, to the extent entitled.
Pay to:
(Name)
(Phone Number)
(Mailing Address)
(E-mail Address)
4. Description of securities and/or related payments:
TITLE OF SECURITY
ISSUE
DATE
FACE AMOUNT IDENTIFYING NUMBER REGISTRATION
FS Form 1050 Department of the Treasury | Bureau of the Fiscal Service 1
RESET
PART C - 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. The
United States is not liable to any person for the improper payment of securities. 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.
You must wait until you are in the presence of a certifying officer to sign this form.
(SEAL)*
(Signature of individual creditor or name of organizational creditor)
By
* There is no seal
(Signature and title of officer of organizational creditor)
Instructions to Certifying Officer: 1. Name of the person(s) who appeared and date of appearance MUST be completed.
2. Medallion stamps require an original signature. 3. Person(s) must sign in your presence.
I certify that
, whose identity(ies) is/are known or
(Name[s] of Person[s] Who Appeared)
proven to me, personally appeared before me this
day of
,
(Month/Year)
at
, and signed this form.
(City, State)
(OFFICIAL STAMP OR SEAL)
ACCEPTABLE CERTIFICATIONS:
Financial Institution's Official Seal or Stamp
(such as Corporate Seal, Signature Guaranteed
Stamp, or Medallion Stamp). Brokers must
use a Medallion Stamp.
(Signature and Title of Certifying Officer)
(Name of Financial Institution)
(Address)
(City/State/ZIP Code)
(Telephone)
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
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 06 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 the above address; send to the address shown in the
instructions.
FS Form 1050 Department of the Treasury | Bureau of the Fiscal Service 2
INSTRUCTIONS
USE OF FORM – An unpaid creditor must complete this form to request payment of United States Securities and/or related
payments belonging to a decedent’s estate unless:
• A legal representative has been or will be appointed through the court.
• The estate will 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.).
• The debt has been barred by any applicable law.
• The total of all securities and/or related payments owned by the decedent as of the date of death exceeds
$100,000 redemption and/or par value.
• There is an individual entitled to the estate according to the law of the decedent’s domicile.
If any of these circumstances apply, do not complete this form. Instead, send the securities and all evidence and/or
documentation concerning the estate to the address shown in “WHERE TO SEND” on the last page of these instructions.
Upon review of the submission, we will provide additional instructions, if necessary.
If you need more space for any item, use a plain sheet of paper or make photocopies 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
Note: The decedent’s Social Security Number will be used to report the interest earned to the Internal Revenue Service for
Federal income tax purposes.
PART B – PAYMENT TO CREDITOR
Provide the information below and submit any supporting documentation (e.g. receipts, statements, invoices).
Payment will be limited to the amount of the debt as shown in the documentation submitted and will not exceed
the value of the securities. (Reissue is not permitted.)
1. Provide the amount owed.
2. Provide the nature of the claim (how the debt was incurred).
3. Provide the creditor’s name, phone number, mailing address, and, if he or she has one, e-mail address.
4. 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.
• REGISTRATION – Provide the registration of each security, check, or account; also provide the account number, if any.
FS Form 1050 Department of the Treasury | Bureau of the Fiscal Service 3
PART B – PAYMENT TO CREDITOR
(Continued)
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 #
IAAAB
ACCT # N-111-11-1111
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 unsur
e what to provide in each of the areas, furnish all identifying information in the space for REGISTRATION.
PART C – SIGNATURES AND CERTIFICATIONS
SIGNATURES – The application must be signed in ink.
If the creditor is an…
The form must be signed by…
And the following must be provided…
Individual
The individual
N/A
Organization
A person authorized to sign on
behalf of the organization
Evidence of the signer’s authority, his or her title, and the
name and seal of the organization
Partnership
A general partner
Signer’s title and the name and seal of the partnership
Corporation An authorized officer of the
corporation
Evidence of the signer’s authority, his or her title, and the
name and seal of the corporation
Note: If the organization, partnership, or corporation has no seal, mark the box provided.
Where evidence of your authority is required, please provide a resolution or other similar documentation.
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.
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, send this form, all securities and/or related
checks, and any necessary evidence to the appropriate address below. (Don't send Instructions pages.)
• Definitive (paper) savings bonds only – Treasury Retail Securities Site, PO Box 214, Minneapolis, MN 55480-0214
• Securities held in TreasuryDirect – Treasury Retail Securities Site, PO Box 7015, Minneapolis, MN 55480-7015
• Securities held in Legacy Treasury Direct – Treasury Retail Securities Site, PO Box 9150, Minneapolis, MN 55480-9150
• Definitive (paper) marketable securities – Treasury Retail Securities Site, PO Box 9150, Minneapolis, MN 55480-9150
Note: You must use only one form and describe all of the securities.
FS Form 1050
Department of the Treasury | Bureau of the Fiscal Service 4
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Sav1050 FS Form 1050

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Completed 12 July 2020

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