FS Form 5396 Department of the Treasury | Bureau of the Fiscal Service 1
OMB No. 1530-0050
FS Form 5396 (Revised August 2019)
Direct Deposit
Sign-Up Form
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.
Check one or both boxes: Interest payments Redemption payments
Check this box if the address furnished below should NOT be used to update HH and H accounts.
Name (or names if joint account) ______________________________________________________________________________
Home Address ________________________________________ ______________________________________________
(Number and Street, Rural Route, or PO Box) (Daytime Telephone Number)
_____________________________________________________ ______________________________________________
(City) (State) (ZIP Code) (E-mail Address)
_____________________________________________________ OR ______________________________________________
(Social Security Number) (Employer Identification Number)
Enter the following informati
on OR tape a voided check to the back of this form:
Bank Routing No. (nine digits): _______________________________
_________________________________________ Type of Account Checking Savings
(Depositor’s Account No.)
___________________________________________________ ______________________________
(Financial Institution’s Name) (Financial Institution’s Phone No.)
For a joint account, only the person whose Taxpayer Identification Number is shown should sign the form.
Under penalty of perjury, I certify that:
1. The Taxpayer Identification Number shown on this form is my correct Taxpayer Identification Number, and
2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the
Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends,
or (c) I have been notified by the Internal Revenue Service that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien).
Instructions - You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return.
_____________________________________________________________________________ __________________________
(Date)
INSTRUCTIONS: Complete and sign this form to request direct deposit of either a redemption payment for any series savings bond or
interest payments of Series HH or Series H savings bonds. Unless otherwise notified, the address and direct deposit information
furnished will be updated on all HH and H accounts under the Taxpayer Identification Number provided.
WHERE TO SEND – Unless otherwise instructed, send the completed and signed form and, if applicable, the properly signed and
certified bond(s), as well as any other appropriate forms and evidence, to:
• HH and H savings bonds – Treasury R
etail Securities Services, PO Box 2186, Minneapolis, MN 55480-2186
• Other paper savings bonds – Treasury Retail Securities Services, PO Box 214, Minneapolis, MN 55480-0214
(phone: 844-284-2676—toll free). Note: Legal evidence or documentation you submit cannot be returned.
NOTICE UNDER PRIVACY ACT AND PAPERWORK REDUCTION ACT
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 10 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 this address; send to the address shown above in "WHERE TO SEND."
For official use only: Customer Name
