Form Pd F 1455 - Request By Fiduciary For Distribution Of United States Treasury Securities Page 3

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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, 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 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)
⇒
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)
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)
, and signed this form.
at
(City)
(State)
(Signature and Title of Certifying Officer)
(OFFICIAL STAMP
OR SEAL)
(Number and Street or Rural Route)
ACCEPTABLE CERTIFICATIONS: Financial Institution’s
Official Seal or Stamp (Such as Corporate Seal, Signature
(City)
(State)
(ZIP Code)
Guaranteed Stamp, or Medallion Stamp).
I CERTIFY that
, whose identity is known or was
proven to me, personally appeared before me this
day of
,
,
(Month)
(Year)
, and signed this form.
at
(City)
(State)
(Signature and Title of Certifying Officer)
(OFFICIAL STAMP
OR SEAL)
(Number and Street or Rural Route)
ACCEPTABLE CERTIFICATIONS: Financial Institution’s
Official Seal or Stamp (Such as Corporate Seal, Signature
(City)
(State)
(ZIP Code)
Guaranteed Stamp, or Medallion Stamp).
(3)
PD F 1455

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