Form Pd F 1455 - Request By Fiduciary For Distribution Of United States Treasury Securities Page 5

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PART B – DISTRIBUTION OF SECURITIES AND PAYMENTS (Continued)

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/she must complete the request on the reverse of the bond.

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.

PART C – SIGNATURES AND CERTIFICATIONS

SIGNATURES – The application 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

ABC National Bank

MEDALLION GUARANTEED

Hillview Branch

Generic Brokerage

Authorized Signature

XXXXXXXX

SECURITIES TRANSFER AGENTS MEDALLION PROGRAM

[Bar Code]

ADDITIONAL EVIDENCE – The Commissioner of the Public Debt, as designee of the Secretary of the Treasury, reserves

the right in any particular case to require the submission of additional evidence.

RETURN OF EVIDENCE – If you want the evidence submitted with this form returned to you, please provide a written

request when you submit the form and evidence.

WHERE TO SEND – Unless otherwise instructed in accompanying correspondence, send to the Department of the

Treasury, Bureau of the Public Debt, using the address listed below:

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

Book entry savings bonds – PO Box 7015, Parkersburg, WV 26106-7015

Series H or Series HH Savings Bonds – PO Box 2186, Parkersburg, WV 26106-2186

All marketable securities– PO Box 426, Parkersburg, WV 26106-0426

PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE

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 Public Debt 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 Public Debt 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 Public Debt, Forms Management Officer, Parkersburg, WV

26106-1328. DO NOT SEND completed form to this address; send to the correct address shown in "WHERE TO SEND" in the instructions.

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PD F 1455