Form Pd F 1455 - Request By Fiduciary For Distribution Of United States Treasury Securities Page 4

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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 (e.g., termination
of trust, distribution of an estate, attainment of majority, restoration to competency).
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 – REASON FOR DISTRIBUTION
Mark the box to show the reason for the distribution. If you mark “Other,” describe the reason.
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.
PART B – DISTRIBUTION OF SECURITIES AND PAYMENTS
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
123
5/15/79
$5,000
2004-2009 MATURES 5/15/09
SSN 222-22-2222
CUSIP 912810CG1
ACCT # 4800-123-1234
Electronic Marketable Security
JOHN DOE
2/5/04
$1,000
CUSIP 912795QW4
SSN 222-22-2222
Confirmation #
ACCT # N-111-11-1111
Electronic Series I Savings Bond
1/1/02
$100
12345
SERIES I
JOHN DOE
SSN 222-22-2222
Serial #
Paper Series EE Savings Bond
7/99
$100
JOHN DOE
C-123,456,789-EE
SERIES EE
OR JANE DOE
Check #
Check
7/26/04
$351.02
JOHN DOE
502123456
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; or 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.
Part B continued next page
(4)
PD F 1455

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