Fill - Security Transfer Request (Department of the Treasury

FS Form 5179 Department of the Treasury | Bureau of the Fiscal Service 1

FS Form 5179 (Revised August 2019) OMB No. 1530-0042

Legacy Treasury Direct

Security Transfer Request

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. This form will not be accepted if it has any alterations or corrections.

1. LEGACY TREASURY DIRECT ACCOUNT INFORMATION

Legacy Treasury Direct ACCOUNT NUMBER: ____________________________________

ACCOUNT NAME: __________________________________________________________________________________

__________________________________________________________________________________________________

2. SECURITIES IDENTIFICATION AND AMOUNT

Transfer ALL my securities for the above Legacy Treasury Direct Account.

Transfer my securities totaling $ ____________ from the CUSIPs below.

(Additional forms are required for more than 9 CUSIPs)

CUSIP AMOUNT CUSIP AMOUNT CUSIP AMOUNT

____________ $____________ ____________ $____________ ____________ $____________

Transfer $ ____________ of my holdings for CUSIP number ____________

(If you are NOT transferring all of your holdings for this CUSIP, you must also list the specific sub-accounts and amounts to

be transferred below. This information is shown on your Legacy Treasury Direct Statement of Account.)

SUB-ACCOUNT AMOUNT SUB-ACCOUNT AMOUNT SUB-ACCOUNT AMOUNT

____________ $____________ ____________ $____________ ____________ $____________

3. TRANSFER INSTRUCTIONS – Check only one transfer option box and provide the requested information

Internal transfer to another Legacy Treasury Direct account – Identify, in the spaces below, the account you want

to receive the transferred securities. It must be an existing account; new accounts are not available.

Legacy Treasury Direct account number ____________________________

Legacy Treasury Direct account name ___________________________________________________________________

__________________________________________________________________________________________________

Taxpayer Identification Number of first-named owner (if available):

__________________________________ OR ________________________________

Social Security Number Employer Identification Number

Transfer to an established online TreasuryDirect account – Identify, in the spaces below, the account you want to

receive the transferred securities.

TreasuryDirect account number _______________________________

(May be established at www.treasurydirect.gov)

TreasuryDirect account name __________________________________________________________________________

__________________________________________________________________________________________________

Taxpayer Identification Number of first-named owner (if available):

__________________________________ OR ________________________________

Social Security Number Employer Identification Number

RESET

For official use only: Customer Name

Case or SR#

Customer No

FS Form 5179

Department of the Treasury | Bureau of the Fiscal Service 2

External Transfer to a Financial Institution or Brokerage Firm

Failure to provide any of the following information could delay the transfer. See Instructions before completing.

Routing Number: ____________________________________________________

Financial Institution Wire Name: __________________________________________________

Agent or Broker Name and Phone Number: ___________________________________________

Agent or Broker Address: __________________________________________________________

Special Handling Instructions: _____________________________________________________________________

_______________________________________________________________________________________________

Mark this box if the transfer is between spouses or incident to a divorce.

4. SIGNATURES AND CERTIFICATION

Under penalties of perjury, I/we certify that the information provided on this form is true, correct, and complete.

If there are two owners joined by the word "and," both must sign.

Instructions to Certifying Officer: 1. Name(s) of the person(s) who appeared and date of appearance MUST be completed.

2. If a Medallion stamp is used, an original signature is required. 3. Person(s) must sign in your presence.

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)

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)

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)

(Signature)

FS Form 5179 Department of the Treasury | Bureau of the Fiscal Service 3

INSTRUCTIONS

1. LEGACY TREASURY DIRECT ACCOUNT INFORMATION

Print your Legacy Treasury Direct Account Number and the Account Name (registration) as stated on your Legacy Treasury

Direct Statement of Account.

. S

ECURITIES IDENTIFICATION AND AMOUNT

Check the boxes which apply and provide the information requested. All required information is listed on your Legacy

Treasury Direct Statement of Account.

• To transfer ALL the securities in the Legacy Treasury Direct account listed in Section 1, check the first box.

• To transfer one or more securities in your Legacy Treasury Direct account, check the second box and enter the

o total dollar amount of the securities being transferred,

o CUSIP number (for example, 912795XXX) which identifies the securities being transferred (located under

the heading “Security” on your Statement of Account),

o amount or total par of the CUSIP being transferred.

• To transfer a portion of one security in your Legacy Treasury Direct account, check the third box and enter the

o dollar amount of only the security being transferred,

o CUSIP number of the security being transferred.

o To transfer security sub-account(s), enter the sub-account number(s) and dollar amount(s) to be

ransferred. THE AMOUNT TO BE TRANSFERRED AND THE AMOUNT REMAINING IN THE CUSIP

MUST SATISFY BOTH THE MINIMUM AND MULTIPLE HOLDING REQUIREMENTS FOR THE

SECURITY.

RANSFER INSTRUCTIONS – Choose only one transfer option

Internal transfer to another Legacy Treasury Direct account -

Check the box to transfer your securities to another Legacy

Treasury Direct account number. The transfer must be to an existing account; new accounts aren’t available. Enter the

• account number of the account receiving the transferred securities,

• name on the account receiving the transferred securities (as shown on the transferee’s Statement of Account),

• Taxpayer Identification Number (if available) on the account receiving the transferred securities.

Transfer to an on-line TreasuryDirect account -

Check the box to transfer your securities to an online TreasuryDirect account

number and provide the

• account number of the account receiving the transferred securities,

• name on the account receiving the transferred securities,

• Taxpayer Identification Number (if available) on the account receiving the transferred securities.

External Transfer to a Financial Institution or Brokerage Firm -

Check the box to transfer your securities to a financial

institution for safekeeping or sale. Contact the financial institution for their book-entry delivery instructions. Please note: Securities

CANNOT be transferred to a checking or savings account. Provide the following information:

• Routing Number – ABA (identification) number of the financial institution receiving the securities.

• Financial Institution Wire Name – The institution’s book-entry delivery instructions. Instructions include th

eceiving bank’s name and safekeeping account number OR the receiving bank’s name and the brokerage firm’s

name (these must be in the approved telegraphic abbreviation “short” form).

• Agent or Broker Name and Phone Number.

• Special Handling Instructions – The customer name and account number at the financial institution for delivery of

securities and any other instructions required by the financial institution, such as the name and telephone number of

the person to be contacted at the financial institution for questions about the securities.

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)

FS Form 5179

Department of the Treasury | Bureau of the Fiscal Service 4

Examples: To a financial institution for safekeeping:

To a financial institution for transfer to a brokerage firm:

Routing Number: XXXXXXXXX

Financial Institution Wire Name: ABC BK/TRUST

Special Handling Instructions: FURTHER CREDIT TO

JOHN DOE TRUST ACCOUNT NUMBER XXXXX

Routing Number: XXXXXXXXX

Financial Institution Wire Name: ABC BK/TRUST

Special Handling Instructions: FURTHER CREDIT TO

JOHN DOE BROKERAGE ACCOUNT NUMBER XXXXX

If the box by Mark this Box is not checked we will assume the transfer is neither between spouses nor incident to a divorce.

. S

IGNATURES AND CERTIFICATION

Sign the request in the presence of an authorized certifying officer. Identification may be required. Remember, if there ar

wo owners joined by the word “and,” both must sign (for example, John Doe and Mary Doe). In case there are questions

about this transfer, please provide a mailing address, daytime telephone number, and, if applicable, e-mail address.

Certification of your signature is required. Acceptable certifying officers include authorized employees of insured depository

nstitutions and corporate central credit unions. Brokers must use a medallion stamp. Certification date and address of

financial institution or broker is required. Please note: Certification by a notary public is NOT acceptable.

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 payin

agen

t 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 Medallio

rograms.

Sample certification for a financial institution:

Acceptable certification for a brokerage:

SIGNATURE GUARANTEED

ABC National Bank

Hillview Branch

SIGNATURE GUARANTEED

MEDALLION GUARANTEED

Generic Brokerage

Authorized Signature

XXXXXXXX

SECURITIES TRANSFER AGENTS MEDALLION

PROGRAM

[Bar Code]

WHERE TO SEND - Legal evidence or documentation you submit cannot be returned.

If requesting a transfer to another Legacy Treasury Direct account or to a financial institution, mail this form to Treasury

Retail Securities Site, PO Box 9150, Minneapolis, MN 55480-9150.

If requesting a transfer to an online TreasuryDirect account, mail this form to Treasury Retail Securities Site, PO Box 7015,

Minneapolis, MN 55480-7015.

To ensure timely processing, this form must be received at least ten business days in advance of

• the maturity date of the security

• an interest payment date for the security

Call us toll-free in the United States at 844-284-2676. Outside the U.S.? Call us at +1-304-480-6464

CONFIRMATION OF THE TRANSFER -

You will receive a Legacy Treasury Direct Statement of Account after your securities have

been transferred. Under certain circumstances, there may be a hold on the account and a statement won’t be mailed.

NOTICE UNDER THE 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 appropriate address shown in “WHERE TO SEND” in the Instructions.

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