Form Pd F 4000 E – Fill Out and Use This PDF

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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

PART A – NEW BOND REGISTRATION

(If you need more space to describe your bonds, use page 4.)

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 Public Debt 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 any 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.

4.Delivery instructions, if different from above:

(Name)

(Number and Street or Rural Route)

Reserved for Identification Notations

INSTRUCTIONS TO CERTIFYING OFFICER

Each person appearing before you must establish identification by positive and reliable evidence before this form is signed, unless he or she is personally known to you. You must place an adequate notation in the area reserved for identification notations in Part C or on a separate record, showing exactly how identification was established. A notation is adequate if it is sufficiently detailed to permit, at a later date, a determination of the exact identification actually used. You and, if you are an officer or employee of an organization, the organization will be held fully responsible for the adequacy of the identification.

The signatures to the request must be executed in your presence. Fully complete and sign the certification form provided for your use for each signature you witness.

If you are an employee (rather than an officer) authorized to certify signatures, insert the words “Authorized Signature” in the space provided for the title. Insert the place and date, as required on the form, and impress the seal of your organization.

FOR FEDERAL RESERVE BANK USE ONLY

This transaction was a reportable event.

This transaction was not a reportable event. No interest was reported.

DESCRIBE ADDITIONAL BONDS BELOW

INSTRUCTIONS

USE OF FORM – Complete this form to reissue paper (definitive) Series EE, E, HH, H, and I United States Savings Bonds, Retirement Plan Bonds, and Individual Retirement Bonds. A separate Part A must be used for each new form of registration. If more space is needed for any item, use a plain sheet of paper or make photocopies, as necessary, and attach to the form. To request payment, sign the backs of the bonds instead of completing this form.

INCOMPETENT OR MINOR – A minor of sufficient age and competency to sign the request and to understand the nature of the transaction may request reissue of the bonds. A minor under legal guardianship may not request reissue. An incompetent owner, coowner or beneficiary may not request reissue.

PART A – NEW BOND REGISTRATION

1.Describe the bonds to be reissued.

2.Mark the box “In full” if the person listed in Item 3 is to receive the entire value of the bond(s) described in Item 1; or if the person listed in Item 3 is not to receive the entire value, mark the second box and provide the appropriate amount, fractional share, or percentage he/she is to receive.

3.Provide the following information:

a. The appropriate taxpayer identification number (social security number or employer identification number).

c. Mailing information. This address will be shown on the new bonds, unless alternate delivery instructions are provided in Item 4.

d. To add a coowner or beneficiary, mark the appropriate box and insert his/her name. If a name is shown and no box is marked, coownership will be assumed.

4.To have the bonds mailed to an address other than the address shown in Item 3, provide the name and address of the person or institution receiving them. This address will be shown on the new bonds.

PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE

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 Public Debt 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 Public Debt 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 Public Debt, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form to the above address; send to correct address shown in “Where to send” in the Instructions.

PART B – REASON FOR REISSUE

Describe the reason for the reissue. The chart below shows common reasons for reissue. These may not be authorized for all Series. Complete guidelines for authorized reissue transactions may be found in the regulations, in the following Department Circulars: DC 530 (Series E/H), DC 3-80 (Series EE/HH), DC 2-98 (Series I), DC 1-75 (IRB), and DC 1-63 (RPB).

PART C – SIGNATURES AND CERTIFICATIONS

SIGNATURES - Sign the form in ink, in the presence of an authorized certifying officer. The form must be signed as indicated in Part B of the instructions. 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.

If an owner/coowner's name has been changed by marriage, divorce, court order, naturalization, or otherwise, he/she must sign the form as follows: " (PRESENT LEGAL NAME) ", changed by (specify manner in which change occurred) from " (NAME AS ON BONDS)." To support a change of name, other than by marriage, a complete statement should follow the signature to show exactly how the change of name was authorized. Evidence may be required.

CERTIFICATION – Each person whose signature is required must appear before and establish identification to the satisfaction of an authorized certifying officer. If a minor owner or coowner signs the request, the officer must be satisfied that the minor is of sufficient competency to understand the nature of the transaction. 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.

ADDITIONAL REQUIREMENTS FOR SERIES HH/H BONDS:

•Under the Interest Dividend Tax Compliance Act of 1983 as implemented by Internal Revenue Service regulations, the new owner or first-named coowner must complete IRS Form W-9 to certify that the social security number furnished is correct, to indicate whether or not he/she is subject to backup withholding under the provision of Section 3406(a)(1)(C) of the Internal Revenue Code, and to verify that he/she is a United States person (including a U.S. resident alien). Forms W-9 are available at financial institutions in the United States and Internal Revenue Offices. These forms can also be found on the IRS website at the address www.irs.gov.

•The furnishing of Direct Deposit information is a condition of reissue of Series HH bonds bearing issue dates of October 1989 and thereafter. A Direct Deposit form, PD F 5396 or SF 1199A, must be completed for Series HH bonds dated October 1989 and thereafter which are submitted for reissue. The Direct Deposit form must be completed by the new owner or coowner providing the appropriate information for direct deposit of the semi-annual interest payments. Forms SF 1199A are available at financial institutions in the United States. PD F 5396 is available for download on the Internet using the "forms" link at the address www.treasurydirect.gov. The financial institution designated to receive the payment can assist in the completion of the Direct Deposit form.

ADDITIONAL EVIDENCE – The Commissioner of the Public Debt, as designee of the Secretary of the Treasury, reserves the right, in any particular case, to require the submission of additional evidence.

RETURN OF EVIDENCE - If the evidence submitted with this form is to be returned, provide a written request when the evidence is submitted.

WHERE TO SEND – Unless otherwise instructed, the PD F 4000 and the bonds, as well as any other appropriate forms and evidence, must be sent to one of the Treasury Retail Securities Sites shown below: