Form Pd F 5394 – Fill Out and Use This PDF

PART E - SIGNATURES AND CERTIFICATIONS

The undersigned certify under penalty of perjury that the information provided herein is true and correct to the best of our knowledge and belief and agree to distribution of the securities as indicated in Part D. We bind ourselves, our heirs, legatees, successors and assigns, jointly and severally, to hold the United States harmless on account of the transaction requested, 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. We consent to the release of any information regarding this transaction, including information contained in this application, 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 Signature)(Daytime Telephone Number)

Address:

(Number and Street, Rural Route, or PO Box)

(City)

(State)

(ZIP Code)

E-Mail Address:

Sign Here: ⇒

(Applicant's Signature)(Daytime Telephone Number)

Address:

(Number and Street, Rural Route, or PO Box)

(City)

(State)

(ZIP Code)

E-Mail Address:

Sign Here: ⇒

(Applicant's Signature)(Daytime Telephone Number)

Address:

(Number and Street, Rural Route, or PO Box)

(City)

(State)

(ZIP Code)

E-Mail Address:

Sign Here: ⇒

(Applicant's Signature)(Daytime Telephone Number)

Address:

(Number and Street, Rural Route, or PO Box)

(City)

(State)

(ZIP Code)

E-Mail Address:

Sign Here: ⇒

(Applicant's Signature)(Daytime Telephone Number)

Address:

(Number and Street, Rural Route, or PO Box)

(City)

(State)

(ZIP Code)

E-Mail Address:

Person to contact if additional information is necessary:

(Name, Daytime Telephone Number, and E-Mail Address, if applicable)

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PD F 5394

Certifying Officer - The individuals must sign in your presence. You must complete the certification and affix your stamp or seal.

I CERTIFY that

, whose identity is known or was

proven to me, personally appeared before me this

day of

,

,

(Month)

(Year)

at

, and signed this form.

(City)

(State)

(OFFICIAL STAMP

(Signature and title of certifying officer)

OR SEAL)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

I CERTIFY that

, whose identity is known or was

proven to me, personally appeared before me this

day of

,

,

(Month)

(Year)

at

, and signed this form.

(City)

(State)

(OFFICIAL STAMP

(Signature and title of certifying officer)

OR SEAL)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

I CERTIFY that

, whose identity is known or was

proven to me, personally appeared before me this

day of

,

,

(Month)

(Year)

at

, and signed this form.

(City)

(State)

(OFFICIAL STAMP

(Signature and title of certifying officer)

OR SEAL)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

I CERTIFY that

, whose identity is known or was

proven to me, personally appeared before me this

day of

,

,

(Month)

(Year)

at

, and signed this form.

(City)

(State)

(OFFICIAL STAMP

(Signature and title of certifying officer)

OR SEAL)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

I CERTIFY that

, whose identity is known or was

proven to me, personally appeared before me this

day of

,

,

(Month)

(Year)

at

, and signed this form.

(City)

(State)

(OFFICIAL STAMP

(Signature and title of certifying officer)

OR SEAL)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

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PD F 5394

INSTRUCTIONS

USE OF FORM – Use this form to request disposition of United States Treasury Securities (Treasury Bills, Notes, Bonds, TIPS, Savings Bonds, and Savings Notes) and/or related payments belonging to a decedent’s estate, under the following circumstances:

The estate was formally administered through the court and has been closed.

The estate is being settled in accordance with State statute such as Summary Administration, Small Estates Acts, Texas Muniment of Title, Louisiana Judgment of Possession, etc., without the necessity of the court appointing an administrator, executor, or similar legal representative.

ATTACHMENTS – If more space is needed for any item, use a plain sheet of paper or make photocopies, as necessary, and attach to the form.

PART A – DECEDENT’S INFORMATION

Provide the requested information regarding the decedent. If more than one deceased person is named on the securities, provide the information for the person who died last.

Insert the following information:

The decedent’s name

The decedent’s Social Security Number

The state of the decedent’s last legal residence

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

PART B – CIRCUMSTANCES OF REQUEST

Mark the appropriate box to indicate the circumstances under which you are using this form.

Mark box 1 if the estate has been settled through court proceedings and the legal representative is no longer acting.

Mark box 2 if the estate is being settled in accordance with State statute (for example: Summary Administration, Small Estates Act, Texas Muniment of Title, or Louisiana Judgment of Possession).

Evidence Requirements:

If the estate is closed, submit a certified copy under court seal of the final account or decree of distribution, if any.

If the estate is being settled in accordance with State statute, submit the original or a copy, certified under court seal (if filed with the court), of the evidence making distribution of the securities and/or payments or establishing your authority to collect the proceeds of the estate in accordance with the State law or statute.

PART C – PERSONS ENTITLED

List all persons entitled to collect the securities and/or payments through the decedent’s estate, as established in the supporting evidence.

1. Show each entitled person’s name, the basis of his/her entitlement (i.e., “legatee,” “surviving spouse,” etc.), and his/her

age, if under 21.

2. Show any of the persons listed in Item 1 who are under a legal disability. In the space for “Legal Disability,” enter the nature of the disability, such as the individual is an “incapacitated person.” If appointed by the court, show the legal representative’s name and address. In the space for “Capacity,” enter the official title or description of the representative acting, for example, “legal guardian” or “conservator.” The representative must submit a certified copy under court seal of the letters of appointment dated within one year of submission.

PART D – DISPOSITION OF SECURITIES AND PAYMENTS TO PERSONS ENTITLED

Complete Items 1 through 5.

1.Enter the name of only one entitled person in each Part D, Item 1. (A separate Part D must be completed for each person entitled and each type of distribution desired.) Enter the appropriate social security or employer identification number.

2.Describe only the securities or checks to which the person shown in Item 1 is entitled, in whole or in part:

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 – 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.

Note: If the taxpayer identification number is included in the registration but is masked (i.e. ***-**-1234), please be sure to provide the entire number.

Part D continued on next page.

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PD F 5394

PART D – DISPOSITION OF SECURITIES AND PAYMENTS TO PERSONS ENTITLED (continued from previous page)

EXAMPLES:

TITLE OF SECURITY

ISSUE

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

DATE

Paper Marketable Security

Serial #

9 1/8 % TREASURY BOND OF

JOHN DOE AND BOB DOE

5/15/79

$5,000

123

2004-2009 MATURES 5/15/09

SSN 222-22-2222

CUSIP 912810CG1

Electronic Marketable Security

ACCT # 4800-123-1234

2/5/04

$1,000

JIM DOE

CUSIP 912795QW4

SSN 222-22-2222

Electronic Series I Savings Bond

1/1/02

$100

Confirmation #

ACCT # N-111-11-1111

SERIES I

12345

BOB SMITH

SSN 222-22-2222

Paper Series EE Savings Bond

Serial #

7/99

$100

BILL SMITH

SERIES EE

C-123,456,789-EE

OR JANE SMITH

Check

7/26/04

$351.02

Check #

JIM SMITH

CHECK

502123456

If unsure what to provide in each of the areas, furnish all information shown on the face of the security or check in the space for REGISTRATION.

3.Mark the block “In full” if the person listed in Item 1 is to receive the entire value of the securities and/or checks described in Item 2; or if the person listed in Item 1 is not to receive the entire value, mark the second block and provide the amount, fractional share, or percentage to which he/she is entitled.

4.Check the appropriate block indicating type of distribution for the particular type of security involved (securities can’t be transferred from one type to another). Provide account numbers, if any.

•Provide a separate Part D for each different registration or type of distribution desired.

•In certain circumstances, we may need to request additional forms and/or information in order to complete the requested action. In this event, we will provide any additional forms and/or instructions.

•Requests for reissue or transfer (when applicable) may not be available if there is not sufficient time to process the transaction before the security matures. If we are unable to process the reissue or transfer request before the security matures, payment will be issued. All Saving Bonds of Series A, B, C, D, F, G, J, and K, and Savings Notes have reached final maturity and must be redeemed.

•Any interest which is or becomes due on securities belonging to the estate of the decedent will be paid to the person to whom the securities are distributed, unless otherwise requested.

5.Provide mailing instructions. (If payment by Direct Deposit is desired, complete Item 6 instead.)

6.Provide information on the bank account where the payment is to be direct deposited. All persons requesting payment must sign in Part E of this form. If payment is to be deposited to a bank account in the name of a different person, then that person or his/her representative, who can authorize such a deposit, must also sign in Part E. For marketable Treasury Bills, Notes, Bonds, and TIPS held in book-entry, payment may be made by Direct Deposit only if one individual is entitled to payment.

PART E – SIGNATURES AND CERTIFICATIONS

SIGNATURES – The application must be signed in ink by:

All competent persons listed in Part C, Item 1 and Part D, Item 1.

The legal guardian or similar representative of the estate of any person under legal disability listed in Part C, Item 2 or Part D, Item 1; and

A parent on behalf of any minor listed in Part C, Item 1 or Part D, Item 1.

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 banking institutions, including credit unions.

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 you want the evidence submitted with this form returned to you, please provide a written request when you submit the form and evidence.

WHERE TO SEND – Send the completed form, all of the securities, if any, and required evidence to the appropriate address as shown at the beginning of this form.

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 address shown in "WHERE TO SEND" above.

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PD F 5394