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Supplemental Statement for United States Securities (Department of the Treasury - BPD)

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FS Form 2243 Department of the Treasury | Bureau of the Fiscal Service 1
FS Form 2243 (Rev
ised April 2020)
OMB No. 1530-0021
Supplemental Statement for
United States Securities
IM
PORTANT: 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: For Series EE and Series I savings bonds, we no longer issue substitute bonds in paper form. We issue those substitute bonds
in electronic form, in our online system TreasuryDirect. For information on opening an account in TreasuryDirect, go to
www.treasurydirect.gov.
1. The claim reporting the loss, theft, destruction, or nonreceipt of United States Securities applies to the securities
described in Item 5.
2. The claim reporting the loss, theft, destruction, or nonreceipt of United States Securities applies to the securities
described in Item 5 rather than the securities described in the original application.
3. I c
ertify:
I had
possession, custody, or control of the securities described in Item 5.
I have firsthand knowledge of the circumstances under which the securities described in Item 5 were lost,
stolen, or destroyed.
I had
access to the ______________________________ described in Item 5.
(security or bearer security)
4. I have been informed that _____________________________________________________ submitted a claim
repor
ting the________________________________ of the United States Securities described in Item 5. My knowledge of
(loss, theft, destruction, or nonreceipt)
the security(ies) is:
5. Description of Securities
TITLE OF SECURITY
(Identify securities by series, interest
rate, type, CUSIP, call and maturity
dates, as appropriate)
ISSUE
DATE
FACE AMOUNT
(Denomination)
SERIAL NUMBER
REGISTRATION
(Exactly as shown on the face of each security)
(If you need more space, attach either a list or FS Form 3500 (see www.treasurydirect.gov/forms/sav3500.pdf)
RESET
For official use only: Customer Name
Case or SR#
Customer No
FS Form 2243 Department of the Treasury | Bureau of the Fiscal Service 2
6. If our office has marked this box, please indicate whether you want electronic substitute bonds or payment, and
provide the requested information. NOTE: This applies only to Series EE or Series I savings bonds.
P
lease redeem my bonds and make payment to the financial institution below.
P
ayee must provide a Social Security Number or Employer Identification Number:
______________________________________ OR __________________________________________
(Social Security Number of Payee) (Employer Identification Number of Payee)
________________________________________________________________________________________
(Name/Names on the Account)
Bank Routing No. (nine digits and begins with 0, 1, 2, or 3 ): _______________________________
____
_____________________________________ Type of Account
Checking Savings
(Depositor’s Account No.)
____
_______________________________________________ ______________________________
(Financial Institution’s Name) (Financial Institution’s Phone No.)
P
lease issue substitute bond(s) in electronic form into the following TreasuryDirect account.
Account number: ________________________________________
A
ccount name: _______________________________________________________________________
S
ocial Security Number or Employer Identification Number: ____________________________________
NOTE: You may add a secondary owner or beneficiary once bonds have been replaced in electronic form within your
TreasuryDirect account. For more information, access your account and click on “How do I” at the top of the page to
find instructions on how to add a secondary owner or beneficiary.
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 Branch 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.
7. Signatures and Certification
I/We certify that I/we don't have possession or control of any of the securities described in Item 5 and that I/we don't have any further
information in regard to where they are or what became of them.
I/We severally petition the Secretary of the Treasury for relief as authorized by law and, if relief is granted, acknowledge that the original
securities will become the property of the United States. Upon the granting of relief, I/we assign all our right, title, and interest in the
original securities to the United States and hereby bind myself/ourselves, my/our heirs, executors, administrators, successors and
assigns, jointly and severally: (1) to surrender the original securities to the Department of the Treasury should they come into my/our
possession; (2) to hold the United States harmless on account of any claim by any other parties having, or claiming to have, interests in
these securities; and (3) upon demand by the Department of the Treasury, to indemnify unconditionally the United States and repay to
the Department of the Treasury all sums of money which the Department may pay on account of the redemption of these original
securities, including any interest, administrative costs and penalties, and any other liability or losses incurred as a result of such
redemption.
FS Form 2243 Department of the Treasury | Bureau of the Fiscal Service 3
Sign in ink in the presence of a certifying officer and provide the requested information.
Instructions to Certifying Officer: 1. Name 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.
Here: __________________________________________________________________________________________________
_____________________________________________________ ______________________________________________
(Print Name) (Social Security Number)
Home Address ________________________________________ ______________________________________________
(Number and Street or Rural Route) (Daytime Telephone Number)
_____________________________________________________ ______________________________________________
(City) (State) (ZIP Code) (Email Address)
Here: __________________________________________________________________________________________________
_____________________________________________________ ______________________________________________
(Print Name) (Social Security Number)
Home Address ________________________________________ ______________________________________________
(Number and Street or Rural Route) (Daytime Telephone Number)
_____________________________________________________ ______________________________________________
(City) (State) (ZIP Code) (Email Address)
Here: __________________________________________________________________________________________________
_____________________________________________________ ______________________________________________
(Print Name) (Social Security Number)
Home Address ________________________________________ ______________________________________________
(Number and Street or Rural Route) (Daytime Telephone Number)
_____________________________________________________ ______________________________________________
I CERTIFY that _________________________________________________________________________ whose identity(ies)
Name of Person 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)
__________________
______________________________________ SEE INSTRUCTIONS FOR ACCEPTABLE CERTIFICATION
(Telephone)
(Signature)
(Signature)
(Signature)
FS Form 2243 Department of the Treasury | Bureau of the Fiscal Service 4
INSTRUCTIONS
PURPOSE OF FORM – Use this form to support an application for relief on account of the loss, theft, destruction, or
nonreceipt of United States Securities.
COMPLETION OF FORM
ITEM 1. Mark this box to show that the securities described in Item 5 are the missing securities referred to on the
original application. Describe the missing securities in Item 5.
ITEM 2. Mark this box if incorrect serial numbers were provided on the original application. Describe the correct
missing securities in Item 5.
ITEM 3. Mark the appropriate box(es) to indicate whether you had possession, custody, or control of the securities,
firsthand knowledge of the circumstances under which they were lost, stolen, or destroyed, or if you had
access to the securities.
ITEM 4. Mark this box and complete this item when someone other than the original applicant(s) had custody or
knowledge of the loss. Furnish the name(s) of the original applicant(s) and provide all information
concerning your knowledge of the whereabouts of the securities. If you do not have any knowledge of their
whereabouts, state this. If the original applicant(s) or any other person claims to have mailed or delivered
the securities to you, state whether or not you received them. If you did not receive the securities, explain
why, if known (for example, wrong address used).
I CERTIFY that _________________________________________________________________________ whose identity(ies)
Name of Person 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)
__________________
______________________________________ SEE INSTRUCTIONS FOR ACCEPTABLE CERTIFICATION
(Telephone)
I CERTIFY that ________________________________________________________________________ whose identity(ies)
Name of Person 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)
__________________
______________________________________ SEE INSTRUCTIONS FOR ACCEPTABLE CERTIFICATION
(Telephone)
FS Form 2243 Department of the Treasury | Bureau of the Fiscal Service 5
ITEM 5. Furnish a complete description of the missing securities.
ITEM 6. If our office has marked this box, indicate whether you want payment
or electronic substitute bonds. If you
want payment, provide information about your bank. If you want electronic substitute bonds, provide the
requested TreasuryDirect account information.
ITEM 7. If Item 1 or 2 is checked, the form must be signed by the original applicant(s). If Item 3 or 4 is checked, the
form must be signed by the person having custody of the securities or knowledge of their loss. If any person
whose signature is required is a minor who does not have a court-appointed guardian, the minor may sign
on his or her own behalf for Series HH bonds, if in the opinion of the certifying officer, he or she is of
sufficient competency to understand the nature of the transaction. If not, the form must be signed by both
parents on the minor’s behalf. If you have Series EE or Series I bonds, a minor cannot sign on his or her
own behalf. The form must be signed by the parents. If the minor does not reside with either parent, the
form must be completed and signed by the person who furnishes the minor’s chief support. The minor’s age
and Social Security Number must be furnished.
CERTIFICATION – Each person whose signature is required must appear before and establish identification to the
satisfaction of an authorized certifying officer. 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 payin
g
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 Medallion
Programs
W
HERE TO SEND – Send this form (without instruction pages) and any additional information to the appropriate address:
• HH and H savings bonds – Treasury Retail Securities Services, PO Box 2186, Minneapolis, MN 55480-2186
• Other paper savings bonds – Treasury Retail Securities Services, PO Box 214, Minneapolis, MN 55480-0214
• Securities in TreasuryDirect – Treasury Retail Securities Services, PO Box 7015, Minneapolis, MN 55480-7015
• Securities in Legacy Treasury Direct – Treasury Retail Securities Services, PO Box 9150, Minneapolis, MN 55480-
9150
• Paper marketable securities – Treasury Retail Securities Services, PO Box 9150, Minneapolis, MN 55480-9150
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).
T
he 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 15 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 correct address shown in "WHERE TO SEND"
above.
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Supplemental Statement for United States Securities (Department of the Treasury - BPD)

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Completed 2 February 2021

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