Form Request Fiduciary – Fill Out and Use This PDF

FS Form 1455 (Revised July 2020)

OMB No. 1530-0035

Request by Fiduciary for Distribution of

United States Treasury Securities

IMPORTANT: 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.

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

•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 (a separate Part B must be completed for each distributee)

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

1.Distribute to: ______________________________________________________________________________________________

(Name of first distributee)

_____________________________________________________	____________________________________________
(Social Security Number or Employer Identification Number)	(Telephone Number)

_____________________________________________________________________________________________________________

(Address)

2. Description of securities and/or related payments:

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

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Part B – Distribution of Securities (CONTINUED)

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

1.Distribute to: ______________________________________________________________________________________________

(Name of second distributee)

_____________________________________________________	____________________________________________
(Social Security Number or Employer Identification Number)	(Telephone Number)

_____________________________________________________________________________________________________________

(Address)

2. Description of securities and/or related payments:

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 of third distributee)

_____________________________________________________	____________________________________________
(Social Security Number or Employer Identification Number)	(Telephone Number)

_____________________________________________________________________________________________________________

(Address)

2. Description of securities and/or related payments:

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

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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.

Sign in ink, in your fiduciary capacity, in the presence of a certifying officer, and provide the requested information.

Sign

Here: __________________________________________________________________________________________________

_____________________________________________________			______________________________________________
	(Print Name)		(Social Security Number)
Home Address ________________________________________			______________________________________________
(Number and Street or Rural Route)			(Daytime Telephone Number)
_____________________________________________________			______________________________________________
(City)	(State)	(ZIP Code)	(Email Address)

Sign in ink, in your fiduciary capacity, in the presence of a certifying officer, and provide the requested information.

Sign

Here: __________________________________________________________________________________________________

_____________________________________________________			______________________________________________
	(Print Name)		(Social Security Number)
Home Address ________________________________________			______________________________________________
(Number and Street or Rural Route)			(Daytime Telephone Number)
_____________________________________________________			______________________________________________
(City)	(State)	(ZIP Code)	(Email Address)

Instructions to 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)

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)
________________________________________________________
(Telephone)

FS Form 1455

Department of the Treasury | Bureau of the Fiscal Service

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Instructions to 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)

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)
________________________________________________________
(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 and attach to the form.

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, showing the appointment is still in full force. Submit certified copies of death certificates for all deceased registrants.

Part B – Distribution of Securities (a separate Part B must be completed for each distributee)

Complete Items 1 and 2.

1.Enter the name of only one distributee in each Part B, Item 1. 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

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

DATE

Paper Marketable Security

Serial #

9 1/8 % TREASURY BOND OF

JOHN DOE AND JANE DOE

5/15/79

$5,000

123

2004-2009 MATURES 5/15/09

SSN 222-22-2222

CUSIP 912810CG1

ACCT # 4800-123-1234

Electronic Marketable Security

2/5/04

$1,000

JOHN DOE

CUSIP 912795QW4

SSN 222-22-2222

FS Form 1455

Department of the Treasury | Bureau of the Fiscal Service

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