Fill - United States Treasury Securities Request by Fiduciary for (Triadex Services)

For official use only:

Customer Name

Case Number

OMB No. 1530-0035

FS Form 1455 (revised March 2018)

Request by Fiduciary for Distribution of

United States Treasury Securities

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

One or more fiduciaries (individual or corporate) must use this form to request distribution of United States Treasury Securities to the person

lawfully entitled due to distribution of a trust or an estate or other reasons set out in the instructions.

Part A – Reason for Distribution

I/We request distribution of the securities and/or related payments for the following reason:

Distribution of an estate OR trust to person(s) entitled

Other reason for distribution:

If a person entitled to paper savings bonds (Series EE, E, I, HH, or H) wants . . .

. . . payment, he or she must submit FS Form 1522

If a person entitled to Series HH savings bonds wants . . .

. . . reissue to himself or herself, he or she must submit FS Form 4000

. . . reissue to a trust, he or she must submit FS Form 1851

A person entitled to electronic securities held in TreasuryDirect must submit FS Form 5511 for transfer or FS Form 5512

for redemption.

For forms, go to

www.treasurydirect.gov.

Part B – Distribution of Securities

I/We request that the securities and/or related payments be distributed as follows:

1. Distribute to:

(Name)

(Social Security Number or Employer Identification Number)

(Telephone Number)

(Address)

2. Description of securities and/or related payments:

Title of Security

Issue

Date

Face Amount

Identifying Number

Registration

NOTE: Individual savings bonds (Series EE, E, I, HH, and H) may not be split. Each savings bond must be distributed, in its entirety, to

an entitled individual or entity. Marketable securities may be distributed in full or in increments of $100.

If you want to split a marketable security, describe the exact amount of the distribution:

FS Form 1455 Department of the Treasury | Bureau of the Fiscal Service 1

Part B – Distribution of Securities (Continued)

I/We request that the securities and/or related payments be distributed as follows:

1. Distribute to:

(Name)

(Social Security Number)

(Employer Identification Number)

(Address and Telephone Number)

2. Description of securities:

Title of Security

Issue

Date

Face Amount

Identifying Number

Registration

NOTE: Individual savings bonds (Series EE, E, I, HH, and H) may not be split. Each savings bond must be distributed, in its entirety, to

an entitled individual or entity. Marketable securities may be distributed in full or in increments of $100.

If you want to split a marketable security, describe the exact amount of the distribution:

I/We request that the securities and/or related payments be distributed as follows:

1. Distribute to:

(Name)

(Social Security Number)

(Employer Identification Number)

(Address and Telephone Number)

2. Description of securities:

Title of Security

Issue

Date

Face Amount

Identifying Number

Registration

NOTE: Individual savings bonds (Series EE, E, I, HH, and H) may not be split. Each savings bond must be distributed, in its entirety, to

an entitled individual or entity. Marketable securities may be distributed in full or in increments of $100.

If you want to split a marketable security, describe the exact amount of the distribution:

FS Form 1455 Department of the Treasury | Bureau of the Fiscal Service 2

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, and agree to distribution of the securities as indicated in Part B. I/We bind ourselves, our heirs, legatees, successors and

assigns, jointly and severally, to hold the United States harmless on account of the transaction requested, and 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 form, 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.

Sign Here:

(Applicant’s Title)

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

(Daytime Telephone Number)

(E-Mail Address)

Instructions to Certifying Officer:

1. Name of 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 is known or

(Name of Person Who Appeared)

proven to me, personally appeared before me this

day of

(Month/Year)

, and signed this form.

(City, State)

(OFFICIAL STAMP

OR SEAL)

(Signature and Title of Certifying Officer)

(Name of Financial Institution)

(Address)

(City, State, ZIP Code)

(Telephone)

FS Form 1455 Department of the Treasury | Bureau of the Fiscal Service 3

(Signature)

You must wait until you are in the presence of a certifying officer to sign this form.

Sign Here:

(Applicant’s Title)

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

(Daytime Telephone Number)

(E-Mail Address)

Instructions to Certifying Officer:

1. Name of 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 is known or

(Name of Person Who Appeared)

proven to me, personally appeared before me this

day of

(Month/Year)

, and signed this form.

(City/State)

(OFFICIAL STAMP

OR SEAL)

(Signature and Title of Certifying Officer)

(Name of Financial Institution)

(Address)

(City, State, ZIP Code)

(Telephone)

Instructions

Use of Form – One or more fiduciaries (individual or corporate) must use this form to establish entitlement and request distribution of

United States Treasury Securities and/or related payments to the person lawfully entitled due to termination of a trust, distribution of an

estate, attainment of majority, restoration to competency, or other reason.

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.

NOTE: For reissue of Series HH bonds to the estate, use FS Form 4000. For payment of Series EE, E, I, HH, or H bonds to the estate,

submit FS Form 1522.

Part A – Reason for Distribution

Mark a box to show the reason for the distribution. If you mark “Other,” describe the reason, such as attainment of majority or restoration

to competency. Submit a copy of all evidence that establishes your authority to request this transaction. For example, if you are

the administrator or executor of an estate, provide a certified copy of your letters of appointment, dated within one year of

submission. Submit certified copies of death certificates for all deceased registrants.

FS Form 1455 Department of the Treasury | Bureau of the Fiscal Service 4

(Signature)

Part B – Distribution of Securities

Complete Items 1 through 2.

1. Enter the name of only one distributee in each Part B, Item 1. (A separate Part B must be completed for each distributee.) Enter the

appropriate Social Security Number or Employer Identification Number.

2. Describe only the securities and/or checks which the person shown in Item 1 is to receive:

 TITLE OF SECURITY – Identify each security by series, interest rate, type, CUSIP, 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.

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 #

12345

ACCT # N-111-111-111

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 unsure what to provide in each of the areas, furnish all identifying information in the space for REGISTRATION.

In all cases, we need an additional form or forms from the distributee.

If a person entitled to paper savings bonds (Series EE, E, I, HH, or H) wants . . .

. . . payment, he or she must submit FS Form 1522

If a person entitled to Series HH savings bonds wants . . .

. . . reissue to himself or herself, he or she must submit FS Form 4000

. . . reissue to a trust, he or she must submit FS Form 1851

When electronic securities held in a TreasuryDirect account are distributed, the entitled person must submit FS Form 5511 for transfer or

FS Form 5512 for redemption.

When distributed to an entitled person or entity, individual savings bonds (Series EE, E, I, HH, and H) may not be split. Each bond must

be distributed, in its entirety, to an entitled individual or entity. Marketable securities may be distributed in full or in increments of $100.

To split marketable securities, describe the exact amount of the distribution.

Our forms may be downloaded at www.treasurydirect.gov .

If an entitled person wants payment of paper marketable securities, not held electronically, the fiduciary must complete the assignment on

the reverse of the security. The distributee must complete IRS Form W-9.

Any interest that is or becomes due on securities belonging to the estate of a decedent will be paid to the person to whom the securities

are distributed, unless otherwise requested.

FS Form 1455 Department of the Treasury | Bureau of the Fiscal Service 5

Part C – Signatures and Certifications

Signatures – The form must be signed in ink. Sign the form in your fiduciary capacity. 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.

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 most financial institutions, including

credit unions. 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.

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]

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) and send the

securities, if any, to the appropriate address below. Legal evidence or documentation you submit cannot be returned.

 Series H or Series HH savings bonds – Treasury Retail Securities Site, PO Box 2186, Minneapolis, MN 55480-2186.

 Definitive (paper) savings bonds – Treasury Retail Securities Site, PO Box 214, Minneapolis, MN 55480-0214.

 Book-entry savings bonds and marketable securities held in TreasuryDirect – Treasury Retail Securities Site, PO Box 7015,

Minneapolis, MN 55480-7015.

 Marketable 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.

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 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 completed form to this address; send

to the appropriate address shown in "Where To Send" in the Instructions.

FS Form 1455 Department of the Treasury | Bureau of the Fiscal Service 6

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