Form Tfs-2006 Check Replacement Request And Indemnification Bond (Page 2 of 4) in pdf

CHECK REPLACEMENT REQUEST AND INDEMNIFICATION BOND

(Unendorsed Check)

If the replacement check is to be printed by the

If the replacement check is to be printed by

ERO print location:

HSBC TFS Account Research:

* Do not fax ID bond to HSBC Taxpayer Financial

* Fax completed ID bond to 1-800-709-0034.

Services Inc. (HSBC TFS).

* Retain a copy of the ID bond for your files.

* Retain the completed ID bond in the ERO files.

---to be completed by ERO---

PRIMARY APPLICANT: _________________________________SSN: ________-________-_________

JOINT APPLICANT:_____________________________________SSN: ________-________-_________

CURRENT MAILING ADDRESS: _________________________________________________________

____________________________________________________________________________________

CHECK NUMBER: __________________TELEPHONE NUMBER: ______________________________

REASON FOR REQUESTING CHECK REPLACEMENT: ______________________________________

FILING STATUS ON TAX RETURN:

Single

Married filing joint return

Married filing separate return

Head of Household

Qualifying widow

---to be completed by applicants---

In consideration of a new cashier’s check being issued by HSBC Bank USA, National Association or

HSBC Trust Company (Delaware), National Association ( each referenced herein as “HSBC”), to replace

cashier’s check Number

_________________ in the amount of $ _____________ originally issued on______________________

(date)

(the “Original Cashier’s Check”), the undersigned represent and agree that:

The Original Cashier’s Check was not received or endorsed by the undersigned nor has it been sold, transferred or assigned

by the undersigned. The undersigned agrees, at all times hereafter, to save, defend, hold harmless and indemnify HSBC,

HSBC TFS, and their successors and assigns from and against any and all claims related in any way to the presentation,

collection or attempted collection of the Original Cashier’s Check and from all expenses related thereto, including, but not

limited to, attorney’s fees to the extent allowed by law, resulting from the negligent, reckless, or willful act or omission of the

undersigned.

SIGNATURE: ______________________DATE:__________WITNESS:_________________DATE:_________

ERO Name: ______________________________________ERO Phone #:________________________

(Please print)

Note: Both applicants must sign if the application was signed by both applicants. The ERO must witness at

least one of the signatures above.

TFS-2003 (01/2008)

Form Tfs-2006 Check Replacement Request And Indemnification Bond Page 2