Reissue Savings Bonds – Fill Out and Use This PDF

Request To Reissue United States Savings Bonds

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.

NOTE: When we reissue Series EE or Series I savings bonds, we no longer provide paper bonds. The reissued bonds are in electronic form, in our online system TreasuryDirect. For information on TreasuryDirect, go to www.treasurydirect.gov.

*A savings bond is reissued in electronic form and can be in only one name.

PART B – REISSUES OF SERIES HH BONDS, RETIREMENT PLAN BONDS, AND INDIVIDUAL RETIREMENT BONDS

NOTES: Savings bonds within one month of final maturity cannot be reissued. When reissuing Series HH savings bonds, the owner should also submit FS Form 5396, providing direct-deposit instructions for semi-annual interest payments (see www.treasurydirect.gov to download the form).

1. DESCRIPTION OF BONDS

I/We request reissue of the savings bonds described below, in the amount of $ _________________ total face amount.

(If you need more space, attach either FS Form 3500 [see www.treasurydirect.gov] or a plain sheet of paper.)

2. REQUESTED REGISTRATION

a. Taxpayer Identification Number ________________________________________________________________________________

(Social Security Number or Employer Identification Number)

b. Registration ________________________________________________________________________________________________

(Full name of owner/first named coowner or fiduciary inscription)

c. Mailing Address ____________________________________________________________________________________________

d. To name a coowner or beneficiary select the appropriate box and enter a name:

(Full name of coowner or beneficiary)

(If a name is shown and neither box is marked, coownership will be assumed.)

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 the Bureau of the Fiscal Service 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 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.

3.DESCRIBE THE REASON FOR THE REISSUE ________________________________________________________

__________________________________________________________________________________________________

If the reason shown above is to correct an error in registration, provide the following information:

a. Who purchased the bonds? ________________________________________________________________________

b. Whose funds were used? __________________________________________________________________________

c. How did the error occur? __________________________________________________________________________

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. I/We agree to reissue of the bonds as indicated and certify that the reissue is authorized.

I/We hereby bind ourselves, our heirs, legatees, successors, and assigns, jointly and severally, to hold the United States harmless on account of the reissue requested herein, 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 application, to any party having an ownership or entitlement interest in the bonds.

Persons named on the bonds as well as the TreasuryDirect Account owner or Account Manager (if not the same person) must sign the form.

Sign in ink in the presence of a notary or certifying officer and provide the requested information.

Sign

Here: __________________________________________________________________________________________________

Sign

Here: __________________________________________________________________________________________________

Sign

Here: __________________________________________________________________________________________________

Instructions to Notary or Certifying Officer:

1.Name(s) of the person(s) who appeared and date of appearance MUST be completed.

2.If a Medallion stamp is used an original signature is required.

3.Person(s) must sign in your presence.

PART C – SIGNATURES AND CERTIFICATIONS

SIGNATURES - Sign the form in ink, in the presence of a notary or authorized certifying officer. The form must be signed as indicated in Part C 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 a notary or 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 or coowner's name has been changed by marriage, divorce, court order, naturalization, or otherwise, he or 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 a notary or authorized certifying officer. If a minor owner or coowner signs the request to reissue Series HH bonds, the notary or 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 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

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 this form (without instruction pages), the securities, if any, 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

FOR BOND-RELATED INQUIRIES:

•Email: SavBonds@bpd.treas.gov • Phone: 844-284-2676 (toll free) • Fax: 612-629-4285

NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS

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 the completed form to this address; send it to the address shown in "WHERE TO SEND.”