Fill - Free fillable Sav4000 FSF4000 (Department of the Treasury

FS Form 4000 Department of the Treasury | Bureau of the Fiscal Service 1

OMB No. 1530-0025 FS Form 4000 (Revised February 2019)

Request To Reissue United States Savings Bonds

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.

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 TreasuryDirect, go to www.treasurydirect.gov.

If you are the …

and are

requesting

reissue to …

for EE or I bonds,

complete parts …

for HH bonds,

complete parts

…

Who must sign

& what evidence is needed

Owner Change name A & C B & C

Series EE and I Series HH

Bond owner and

account owner

Owner

Owner Trust Use FS Form 1851 Use FS Form 1851

Use FS Form 1851

rather than this form

Owner named on the bond

Add a coowner or

beneficiary

Form not applicable* B & C Owner

Owner named on the bond

Change or remove

beneficiary

Form not applicable* B & C Owner

Owner named on the bond –

single owner

Remove living

owner to name new

owner

Series EE Series I

B & C

Series EE and I Series HH

A & C

A & C, but

only if

directed by

judicial

proceedings

Owner and new

owner

Owner

(New owner must

give direct-deposit

information on FS

Form 5396)

Owner of bonds in

coownership form

Remove living

coowner

A & C B & C

Series EE and I Series HH

Both coowners

Owner whose

name is being

removed if

another coowner

or beneficiary is

not to be named.

Otherwise, both

coowners must

sign.

(New owner must

give direct-deposit

information on FS

Form 5396)

Surviving registrant

Remove deceased

registrant

Form not applicable* B & C

Living registrant. Send certified copy

of death certificate for decedent.

(For Series HH, owner must give

direct-deposit information on FS

Form 5396)

Purchaser

Correct the

registration of bonds

in single owner or

beneficiary form

A & C B & C

Series EE and I Series HH

Purchaser

(If the purchaser

doesn’t wish to open a

TreasuryDirect

account, the owner

must provide the

TreasuryDirect account

information in part A

and join the purchaser

in signing in part C)

Purchaser

Correct the

registration of bonds

in coownership

form

A & C B & C

Series EE and I Series HH

Purchaser and

both coowners

Purchaser

RESET

For official use only: Customer Name

Case or SR#

Customer No

FS Form 4000 Department of the Treasury | Bureau of the Fiscal Service 2

Entitled person due to a

divorce, legal separation or

annulment

Change ownership

and remove name of

living owner

A & C B & C

Entitled person. Send certified copy

of divorce decree.

or Series HH, new first-named

owner must give direct-deposit

information on FS Form 5396)

Legal guardian

Show legal

guardianship

registration

A & C B & C

Series EE and I Series HH

Legal guardian.

Send certified

copy of letters

of appointment.

he coowner

must also sign

in part C)

Legal guardian.

Send certified

copy of letters of

appointment.

or Series HH,

legal guardian

must give direct-

deposit

information on FS

Form 5396, and, if

TIN is changing,

complete W-9)

Entitled person through

estate or trust

Name a new owner A & C B & C

Entitled person

or Series HH, new owner must give

direct-deposit information on FS

Form 5396)

Legal representative of an

estate

The estate

A & C B & C

urrent legal representative. Send

certified copy of letters of

appointment and death certificate(s)

for decedent(s) named in the

registration of the bond(s).

or Series HH, legal representative

must give direct-deposit information

on FS Form 5396, and, if TIN is

changing, complete W-9)

Successor legal

representative of an estate

Show successor

legal representative

A & C B & C

Successor legal representative.

Current letters of appointment.

or Series HH, successor legal

representative must give direct-

deposit information on FS Form

5396, and, if TIN is changing,

complete W-9)

Successor trustee

Show new

successor trustee

A & C B & C

Successor trustee. Send resignation

letter, death certificate, or court order

showing why original trustee is no

longer acting. Also, send a

Certification of Trust or the complete

trust agreement including any

amendments.

(For Series HH, successor trustee

must give direct-deposit information

on FS Form 5396, and, if TIN is

changing, complete W-9)

*Savings bonds are reissued in electronic form and can be in only one name.

FS Form 4000 Department of the Treasury | Bureau of the Fiscal Service 3

PART A – REISSUES OF SERIES EE AND SERIES I BONDS

NOTES: 1) 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. 2) Series EE and Series I bonds may not be reissued within one month of final maturity.

1. DESCRIPTION OF BONDS

I/We request reissue of the savings bonds described below, in the amount of $ _________________ total face amount.

ISSUE DATE

(Specific month

and year of

purchase)

FACE

AMOUNT

BOND NUMBER

INSCRIPTION

(Provide complete Social Security Number [for example, 123-45-6789], names, including

middle names or initials, and addresses [street, city, state] on the bonds.)

(If you need more space, attach either FS Form 3500 [see www.treasurydirect.gov] or a plain sheet of paper.)

2. I/WE AGREE to reissue the bonds in electronic form in the following TreasuryDirect account:

Account Number __________________ Social Security Number or Employer Identification No. ______________________

Account Name: _____________________________________________________________________________________

NOTE: You may add a secondary owner or beneficiary once bonds have been reissued in electronic form in your TreasuryDirect

account. For instructions, access your account and click “How do I” at the top of the page.

TAX LIABILITY: If the name of a living owner or principal coowner of the bonds is eliminated from the registration, the owner or principal coowner must

include the interest earned and previously unreported on the bonds to the date of the transaction on his or her Federal income tax return for the year of the

reissue. (Both registrants are considered to be coowners when bonds are registered in the form: "A" or "B.") The principal coowner is the coowner who (1)

purchased the bonds with his or her own funds, or (2) received them as a gift, inheritance, or legacy, or as a result of judicial proceedings, and had them

reissued in coownership form, provided he or she has received no contribution in money or money's worth for designating the other coowner on the bonds.

If the reissue is a reportable event, the interest earned on the bonds to the date of the reissue will be reported to the Internal Revenue Service (IRS) by a

Federal Reserve Bank or the Bureau of the Fiscal Service under the Tax Equity and Fiscal Responsibility Act of 1982. THE OBLIGATION TO REPORT

THE INTEREST CANNOT BE TRANSFERRED TO SOMEONE ELSE THROUGH A REISSUE TRANSACTION. If you have questions concerning the tax

consequences, consult the IRS, or write to the Commissioner of Internal Revenue, Washington, DC 20224. Unless we are otherwise informed, the first-

named coowner will be considered the principal coowner for the purpose of this transaction.

3. DESCRIBE THE REASON FOR THE REISSUE ________________________________________________________

__________________________________________________________________________________________________

a. If the reason shown above is to correct an error in registration, provide the following information.

(1) Who purchased the bonds? ________________________________ (2) Whose funds were used? ____________________________

(3) How did the error occur? ______________________________________________________________________________________

(4) How should the bonds have been registered originally?

(a) Social Security Number or Employer Identification Number ____________________________________________________

(b) ___________________________________________________________________________________________________

(Full name of owner/first named coowner or fiduciary inscription)

b. If the bonds will be held in the purchaser’s TreasuryDirect account as gifts please provide:

Name of recipient: _________________________________________ Social Security Number of recipient ________________________

FS Form 4000 Department of the Treasury | Bureau of the Fiscal Service 4

PART B – REISSUES OF SERIES HH BONDS, RETIREMENT PLAN BONDS, AND INDIVIDUAL RETIREMENT BONDS

NOTES: Savings bonds within one month of final maturity cannot be reissued. When reissuing Series HH savings bonds, the owner

should also submit FS Form 5396, providing direct-deposit instructions for semi-annual interest payments (see www.treasurydirect.gov to

download the form).

1. DESCRIPTION OF BONDS

I/We request reissue of the savings bonds described below, in the amount of $ _________________ total face amount.

ISSUE DATE

(Specific month

and year of

purchase)

FACE

AMOUNT

BOND NUMBER

INSCRIPTION

(Provide complete Social Security Number [for example, 123-45-6789], names, including

middle names or initials, and addresses [street, city, state] on the bonds.)

(If you need more space, attach either FS Form 3500 [see www.treasurydirect.gov] or a plain sheet of paper.)

2. REQUESTED REGISTRATION

a. Taxpayer Identification Number ________________________________________________________________________________

(Social Security Number or Employer Identification Number)

b. Registration ________________________________________________________________________________________________

(Full name of owner/first named coowner or fiduciary inscription)

c. Mailing Address ____________________________________________________________________________________________

(Number and Street or Rural Route) (City) (State) (ZIP Code)

d. To name a coowner or beneficiary select the appropriate box and enter a name:

coowner beneficiary (POD) ________________________________________________________________

(Full name of coowner or beneficiary)

(If a name is shown and neither box is marked, coownership will be assumed.)

TAX LIABILITY: If the name of a living owner or principal coowner of the bonds is eliminated from the registration, the owner or principal coowner must

include the interest earned and previously unreported on the bonds to the date of the transaction on his or her Federal income tax return for the year of the

reissue. (Both registrants are considered to be coowners when bonds are registered in the form: "A" or "B.") The principal coowner is the coowner who

(1)

pur

chased the bonds with his or her own funds, or (2) received them as a gift, inheritance, or legacy, or as a result of judicial proceedings, and

had

hem reissued in coownership form, provided he or she has received no contribution in money or money's worth for designating the other coowner on t

bonds. If the reissue is a reportable event, the interest earned on the bonds to the date of the reissue will be reported to the Internal Revenue Service

(

IRS) by a Federal Reserve Bank or the Bureau of the Fiscal Service under the Tax Equity and Fiscal Responsibility Act of 1982. THE OBLIGATION TO

REPORT THE INTEREST CANNOT BE TRANSFERRED TO SOMEONE ELSE THROUGH A REISSUE TRANSACTION. If you have questions

concerning the tax consequences, consult the IRS, or write to the Commissioner of Internal Revenue, Washington, DC 20224. Unless we are otherwi

nformed, the first-named coowner will be considered the principal coowner for the purpose of this transaction.

3. DESCRIBE THE REASON FOR THE REISSUE ________________________________________________________

__________________________________________________________________________________________________

f the reason shown above is to correct an error in registration, provide the following information:

Who purchased the bonds? ________________________________________________________________________

b. Whose funds were used? __________________________________________________________________________

ow did the error occur? __________________________________________________________________________

FS Form 4000 Department of the Treasury | Bureau of the Fiscal Service 5

PART C – SIGNATURES AND CERTIFICATIONS

I/We certify under penalty of perjury that the information provided herein is true and correct to the best of my/our

knowledge and belief. I/We agree to reissue of the bonds as indicated and certify that the reissue is authorized.

I/We hereby bind ourselves, our heirs, legatees, successors, and assigns, jointly and severally, to hold the United States

harmless on account of the reissue requested herein, 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/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 bonds.

The person(s) named on the bond(s) as well as the TreasuryDirect Account owner or Account Manager (if not the same person)

must sign the form.

nstructions to Certifying Officer:

1. Name(s) of the person(s) who appeared and date of appearance MUST be completed.

f a Medallion stamp is used an original signature is required.

erson(s) must sign in your presence.

Sign

Here: __________________________________________________________________________________________________

(Applicant’s title)

_____________________________________________________ ______________________________________________

(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: __________________________________________________________________________________________________

(Applicant’s title)

_____________________________________________________ ______________________________________________

(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: __________________________________________________________________________________________________

(Applicant’s title)

_____________________________________________________ ______________________________________________

(Print Name) (Social Security Number)

Home Address ________________________________________ ______________________________________________

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

_____________________________________________________ ______________________________________________

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

(Applicant's Signature)

FS Form 4000 Department of the Treasury | Bureau of the Fiscal Service 6

I CERTIFY that _______________________________________________________________________________ , whose identity(ies)

(Names of Persons Who Appeared)

is/are known or pr

oven 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)

_____________________________________________

___________

(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)

_____________________________________________

___________

(Telephone)

I CERTIFY that _________________________________________________________________________________ , whose identity(ies)

(Names of Persons Who Appeared)

is/are known or prov

en 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)

_____________________________________________

___________

(Telephone)

FS Form 4000 Department of the Treasury | Bureau of the Fiscal Service 7

INSTRUCTIONS

USE OF FORM – Complete this form to reissue paper (definitive) Series EE, Series HH, and Series I United States Savings Bonds,

Retirement Plan Bonds, and Individual Retirement Bonds. A separate form must be used for each new registration with the corresponding

account number for Series EE and Series I. A separate Part B must be used for each new form of registration for Series HH, Retirement

Plan Bonds, and Individual Retirement Bonds.

To request payment, submit form FS Form 1522 (see www.treasurydirect.gov) instead of this form.

INCOMPETENT OR MINOR –

For Series EE and Series I bonds:

• A minor may not sign a request for reissue

• A minor under legal guardianship may not request reissue

• An incompetent owner, coowner, or beneficiary may not request reissue

• Reissue will be in the name of the minor or incompetent alone

For Series HH bonds:

• A minor of sufficient age and competency to sign the request and to understand the nature of the transaction may request reissue

• A minor under legal guardianship may not request reissue

• An incompetent owner, coowner, or beneficiary may not request reissue

PART A – REISSUES OF SERIES EE AND SERIES I BONDS

Describe the bonds to be reissued into TreasuryDirect.

2. Provide the TreasuryDirect account number, account name, and Social Security Number or Employer Identification Number.

3. Describe the reason for the reissue. If the reason is to correct an error in registration, provide the correct registration.

a. If you are correcting an error in registration, show who bought the bonds, whose funds were used and how the error occurred.

Then provide information on how the bonds should have been registered originally.

b. If the bonds will be held in the purchaser’s TreasuryDirect account as gifts, provide the name and Social Security Number of

the intended recipient.

ART B – REISSUES OF SERIES HH BONDS, RETIREMENT PLAN BONDS, AND INDIVIDUAL RETIREMENT BONDS

1. Describe the bonds to be reissued.

2. Provide the following information:

a. The appropriate Taxpayer Identification Number (Social Security Number or Employer Identification Number).

If the new bonds are to be inscribed in the name of .

Provide this . . .

One person as owner, with or without a beneficiary

The Social Security Number of the owner

Two persons as coowners

The Social Security Number of the first-named coowner

A guardian, custodian, or similar representative of the

estate of a minor, incompetent, or other ward

The Social Security Number of the minor, incompetent, or

other ward

Other fiduciary registration (trustee, administrator of

decedent’s estate, etc.)

The Social Security Number of the grantor of the trust or

decedent or an Employer Identification Number assigned to

the fiduciary estate

b. The new registration. Use as much space as necessary to give either a name (first name, middle name or initial, and last

name) or a fiduciary inscription.

c. Provide your mailing address.

d. If you want to add a coowner or beneficiary, mark the appropriate box and insert his or her name. If there is a name but no

box is marked coownership will be assumed.

3. Describe the reason for the reissue. Complete guidelines for authorized reissue transactions may be found in the regulations, in the

following Department Circulars: DC 3-80 (Series HH), DC 1-75 (Individual Retirement Bonds), and DC 1-63 (Retirement Plan Bonds). If

you’re correcting an error in registration, show who bought the bonds, whose funds were used, and how the error occurred.

FS Form 4000 Department of the Treasury | Bureau of the Fiscal Service 8

PART C – SIGNATURES AND CERTIFICATIONS

SIGNATURES - Sign the form in ink, in the presence of an authorized certifying officer. The form must be signed as indicated in Part C of

the instructions. If the request is on behalf of a corporate fiduciary, the name of the corporation must be given, followed by the signature

and title of an authorized officer. If there are two or more fiduciaries, all must join in the request unless by express statute, decree of

court, or the terms of the instrument under which the fiduciaries are acting, one or more of them may properly execute the request. If an

owner or coowner's name has been changed by marriage, divorce, court order, naturalization, or otherwise, he or she must sign the form

as follows: " (PRESENT LEGAL NAME) ", changed by (specify manner in which change occurred) from " (NAME AS ON BONDS)."

To support a change of name, other than by marriage, a complete statement should follow the signature to show exactly how the change

of name was authorized. Evidence may be required.

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

authorized certifying officer. If a minor owner or coowner signs the request to reissue Series HH bonds, the officer must be satisfied that

the minor is of sufficient competency to understand the nature of the transaction. The signatures to the form must be signed in the

officer's presence. The certifying officer must affix the seal or stamp which is used when certifying requests for payment. Authorized

certifying officers are available at financial institutions, including credit unions, in the United States. 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 – Unless otherwise instructed in accompanying correspondence send this form (without instruction pages), the

securities, if any, and any additional information to the appropriate address. Legal evidence or documentation you submit cannot be

returned.

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

• Other paper savings bonds – Treasury Retail Secur

ities Services, PO Box 214, Minneapolis, MN 55480-0214

FOR BOND-RELATED INQUIRIES:

• Email: SavBonds@bpd.treas.gov • Phone: 844-284-2676 (toll free) • Fax: 612-629-4285

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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