1048 Form – Fill Out and Use This PDF

Sign

Here:___________________________________________________________________________________________________

(Signature)

Instructions to Notary or Certifying Officer: 1. Name(s) of the person(s) who appeared and date of appearance MUST be completed. 2. Original signature is required if a Medallion stamp is used. 3. Person(s) must sign in your presence.

I CERTIFY that _________________________________________________________________________ , whose identity(ies)

(Names of Persons Who Appeared)

I CERTIFY that _________________________________________________________________________ , whose identity(ies)

(Names of Persons Who Appeared)

INSTRUCTIONS

IF YOU LIVE IN A DECLARED DISASTER AREA: You need to complete only parts 1, 5, 6.B. and 7. Write the word “DISASTER” on the top of the first page of the form and on the front of the envelope.

PURPOSE OF FORM – Use this form to apply for relief on account of the loss, theft, or destruction of United States Savings Bonds. "Bonds," as used on this form, refers to Savings Bonds, Savings Notes, Retirement Plan Bonds, or Individual Retirement Bonds.

WHO MAY APPLY – This form must be completed and signed by all persons named on the bonds, or by an authorized representative.

PROOF OF DEATH – If a registrant is deceased, you must submit a certified copy of his or her official death certificate with this form.

LEGAL REPRESENTATIVE – If you were appointed as legal representative because:

the owner is deceased (with no surviving coowner or beneficiary named on the bonds), or

the owner or coowner is a minor, or

the owner or coowner is incapacitated,

complete the form and submit a court certificate or certified copy of your letters of appointment, under court seal and dated within one year of submission, showing the appointment is still in full force. If your name and official capacity are shown in the registration of the bonds, evidence of your appointment is not necessary.

If no legal representative has been appointed for a deceased or incompetent owner, advise the Bureau of the Fiscal Service and additional instructions will be provided.

AMOUNT OF BONDS EXCEEDS $5,000 – If the amount of the bonds involved exceeds $5,000 and an investigation was made by a law enforcement agency or an insurance, transportation, or similar business organization, provide a copy of the report.

COMPLETION OF FORM – Print clearly in ink or type all information requested.

ITEM 1. Describe the missing bonds by bond serial number. If you don't know the bond serial numbers, you must provide the exact issue date or a range of dates, and the Social Security Number, name (including middle name or initial), and complete address (street, city, state) that appear on the bonds. Also state the total number of missing bonds. If you need more space, attach either a “Continuation Sheet for Listing Securities” (FS Form 3500), available at http://www.treasurydirect.gov/forms/sav3500.pdf or a plain sheet of paper.

ITEM 2. Mark the appropriate boxes and provide complete details of the loss, theft, or destruction.

ITEM 3. Provide details regarding your authority to complete a claim for the missing bonds. If you have been court-appointed, see "LEGAL REPRESENTATIVE" above.

ITEM 4. A minor (who does not have a court-appointed guardian) who is requesting payment or who is named on Series HH bonds may complete and sign the form on his or her own behalf if, in the opinion of the notary or certifying officer, he or she is of sufficient competency and understanding to comprehend the nature of the transaction. The parents or parent with whom the minor resides must complete this item if a minor is named on the bonds and he or she is not of sufficient competency and understanding to complete the form on his or her own behalf, or is requesting electronic substitute bonds for Series EE or Series I. Provide the minor’s name, date of birth, Social Security Number, and all other requested information. If the minor does not reside with either parent, the form must be completed and signed by the individual who furnishes the minor’s chief support.

ITEM 5. Indicate whether you want substitute bonds or payment by direct deposit.

For Series EE and Series I bonds, we no longer issue substitute bonds in paper form. We issue those substitute bonds in electronic form, in our online system TreasuryDirect.

If you want substitute Series EE bonds or substitute Series I bonds, provide the TreasuryDirect account number. If you don’t have an account, you may open one at www.treasurydirect.gov.

Series EE and Series I bonds issued February 2003 and later are not eligible for payment until one full year after issue; if payment is requested and such bonds are less than one year old, substitute bonds will be issued instead.

If substitute bonds are requested and a bond is within less than one full calendar month of reaching its final maturity, or has reached final maturity, payment will be made instead.

ITEM 6. Complete either section A, B, or C. Which section is appropriate for you depends on which series of bonds you have and whether you want payment or substitute bonds.

CERTIFICATION – Each person whose signature is required must appear before and establish identification to the satisfaction of a notary or authorized certifying officer. The signatures to the form must be signed in the presence of the notary or officer. The notary or 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. Examples of acceptable seals and stamps:

The seal or stamp of a notary

A 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

WHERE TO SEND – Send this form and any additional information to the address below. Legal evidence or documentation you submit cannot be returned.

Treasury Retail Securities Services, P.O. 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 20 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 in "WHERE TO SEND" in the Instructions.