Pd F 1455 Form PDF Details

Are you responsible for submitting an application or form to the US Patent and Trademark Office (USPTO)? If so, you may be familiar with the PdF 1455 Form. This is one of many documents available through the USPTO that can be used by patent examiners to evaluate potential applications. In this blog post, we will explain what a PdF 1455 Form is, when it should be used, and how it relates to other types of forms and applications in the patent process. Read on to learn more about this complex but important document!

QuestionAnswer
Form NamePd F 1455 Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other names1851, OMB, SSN, distributee

Form Preview Example

For official use only:

 

Customer Name

Customer No.

PD F 1455

REQUEST BY FIDUCIARY FOR DISTRIBUTION OF

OMB No. 1535-0012

Department of the Treasury

UNITED STATES TREASURY SECURITIES

 

Bureau of the Fiscal Service

 

(Revised February 2014)

 

www.treasurydirect.gov

 

 

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 trust

Reason for distribution:

Distribution of an estate to person(s) entitled

If payment is requested by person(s) entitled, submit form PD F 1522. If reissue to person(s) entitled is requested, submit form PD F 4000. If reissue to a trust is requested, submit form PD F 1851.

NOTE: Savings bonds within one month of final maturity cannot be reissued.

For forms, go to www.treasurydirect.gov.

Other:

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)

(Address and Telephone Number)

2. Description of securities and/or related payments:

TITLE OF SECURITY

ISSUE DATE

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

3.Extent of distribution:

In full

(Amount, Fractional Share, or Percentage)

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)

OR

(Employer Identification Number)

(Address and Telephone Number)

2. Description of securities:

TITLE OF SECURITY

ISSUE DATE

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

3.Extent of distribution:

In full

(Amount, Fractional Share, or Percentage)

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)

(Address and Telephone Number)

2. Description of securities:

TITLE OF SECURITY

ISSUE DATE

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

3.Extent of distribution:

In full

(Amount, Fractional Share, or Percentage)

2

PD F 1455

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 Signature)

(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)

at

 

, and signed this form.

 

 

 

 

(City, State)

 

 

 

 

 

 

(Signature and Title of Certifying Officer)

(OFFICIAL STAMP

OR SEAL)

(Name of Financial Institution)

(Address)

ACCEPTABLE CERTIFICATIONS:

Financial Institution’s Official Seal or Stamp (such as Corporate Seal, Signature Guaranteed Stamp, or Medallion Stamp). Brokers must use a Medallion

Stamp.

(City, State, ZIP Code)

(Telephone)

3

PD F 1455

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

Sign Here:

(Applicant's Signature)

(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)

at

 

, and signed this form.

 

 

 

 

(City/State)

 

 

 

 

 

 

(Signature and Title of Certifying Officer)

(OFFICIAL STAMP

OR SEAL)

ACCEPTABLE CERTIFICATIONS:

Financial Institution’s Official Seal or Stamp (such as Corporate Seal, Signature Guaranteed Stamp, or Medallion Stamp). Brokers must use a Medallion

Stamp.

(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 to the estate, use form PD F 4000. For payment to the estate, submit form PD F 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.

4

PD F 1455

PART B – DISTRIBUTION OF SECURITIES

Complete Items 1 through 3.

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, 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 (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:

 

 

 

 

ISSUE

 

 

 

 

 

 

 

 

 

 

 

TITLE OF SECURITY

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Electronic Series I Savings Bond

1/1/02

 

$100

 

 

Confirmation #

 

ACCT # N-111-111-111

 

SERIES I

 

 

12345

 

JOHN DOE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN 222-22-2222

 

Paper Series EE Savings Bond

 

 

 

 

 

 

 

Serial #

 

 

7/99

 

$100

 

 

 

JOHN DOE

 

SERIES EE

 

 

 

C-123,456,789-EE

 

 

 

 

 

 

 

 

 

 

OR JANE DOE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check

7/26/04

 

$351.02

 

 

Check #

 

 

 

 

 

 

502123456

 

 

JOHN DOE

 

CHECK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

3.Mark the box “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. If the person listed in Item 1 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.

In most cases, we will need additional forms and/or information from the distributee. If so, we may contact the distributee directly. If the transaction can be processed without additional forms or information from the distributee, we will send the securities and/or payments directly to the distributee.

Note: If the distributee wants payment of eligible paper securities and the securities are:

•Savings bonds or notes, he or she must complete form PD F 1522.

•Marketable securities, 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 the decedent will be paid to the person to whom the securities are distributed, unless otherwise requested.

5

PD F 1455

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.

Sample certification for a financial institution:

 

Acceptable certification for a brokerage:

SIGNATURE GUARANTEED

 

SIGNATURE GUARANTEED

ABC National Bank

 

MEDALLION GUARANTEED

Hillview Branch

 

Generic Brokerage

 

 

 

Authorized Signature

 

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 to the Department of the Treasury, Bureau of the Fiscal Service, using the appropriate address below:

•Series H or Series HH savings bonds – PO Box 2186, Parkersburg, WV 26106-2186

•Definitive (paper) savings bonds – PO Box 7012, Parkersburg, WV 26106-7012

•Book-entry savings bonds and marketable securities held in TreasuryDirect – PO Box 7015, Parkersburg, WV 26106-7015

•Marketable securities held in Legacy Treasury Direct – PO Box 426, Parkersburg, WV 26106-0426

•Definitive (paper) marketable securities – PO Box 426, Parkersburg, WV 26106-0426

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.

6

PD F 1455

How to Edit Pd F 1455 Form Online for Free

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Completing this PDF typically requires thoroughness. Make sure every single blank field is filled in accurately.

1. The ACCT needs certain details to be entered. Ensure that the following blank fields are complete:

CUSIP writing process clarified (part 1)

2. Immediately after the prior array of blanks is completed, go on to type in the applicable information in all these: FACE AMOUNT, IDENTIFYING NUMBER, REGISTRATION, ISSUE DATE, TITLE OF SECURITY, Extent of distribution, In full, and Amount Fractional Share or.

Step # 2 for submitting CUSIP

3. The following segment is all about IWe request that the securities, Distribute to, Social Security Number, Name, Address and Telephone Number, Employer Identification Number, FACE AMOUNT, IDENTIFYING NUMBER, REGISTRATION, ISSUE DATE, Description of securities, TITLE OF SECURITY, Extent of distribution, In full, and Amount Fractional Share or - complete every one of these blank fields.

Name, FACE AMOUNT, and Extent of distribution inside CUSIP

In terms of Name and FACE AMOUNT, ensure you get them right in this section. Both these could be the most important ones in this PDF.

4. The next section requires your details in the following parts: IWe request that the securities, Distribute to, Social Security Number, Employer Identification Number, Name, Address and Telephone Number, Description of securities, TITLE OF SECURITY, ISSUE DATE, FACE AMOUNT, IDENTIFYING NUMBER, REGISTRATION, Extent of distribution, In full, and Amount Fractional Share or. It is important to give all of the required information to go onward.

Find out how to fill in CUSIP portion 4

5. As you draw near to the finalization of the document, you will find a couple extra points to do. Mainly, You must wait until you are in the, Sign Here, Applicants Signature, Applicants Title, Number and Street Rural Route or, City, State, ZIP Code, Daytime Telephone Number, EMail Address, Instructions to Certifying Officer, I CERTIFY that, Name of Person Who Appeared, whose identity is known or, and proven to me personally appeared should be done.

Completing part 5 in CUSIP

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