For official use only:
PD F 1050 E
CREDITOR'S REQUEST FOR PAYMENT OF
OMB No. 1535-0055
Department of the Treasury
TREASURY SECURITIES BELONGING TO A
Bureau of the Public Debt
DECEDENT’S ESTATE BEING SETTLED WITHOUT ADMINISTRATION
(Revised December 2010)
IMPORTANT: Follow instructions in filling out this form. You should be aware that the making of any false, fictitious, or fraudulent claim or
statement to the United States is a crime that is punishable by fine and/or imprisonment.
PRINT IN INK OR TYPE ALL INFORMATION
An unpaid creditor must complete this form to request payment of United States Securities and/or related payments belonging to a
decedent’s estate that is not being administered. See the instructions for additional information.
Carefully read the instructions before completing this form.
PART A – ESTATE INFORMATION
Provide the information below and submit certified copies of the death certificates for all deceased registrants.
(Name of Deceased Owner - If more than one person named on the securities, the person who died last)
(Decedent’s Social Security Number)
(Jurisdiction of Legal Residence)
By signing this form, I certify that I have read the instructions for the use of this form and I am entitled to make this claim.
If the above statement does not apply, do not complete this form.
Instead, send the securities and all evidence and/or
documentation concerning the estate to the address shown in “WHERE TO SEND” above.
PART B – PAYMENT TO CREDITOR
Provide the information below and submit any supporting documentation (e.g. receipts, statements, invoices).
1. Amount Owed: $____________ 2. Nature of Claim: _______________________________________________________________
3. I hereby certify that the amount owed has not been paid and is still justly due and owing to the below-named creditor. I further certify
that the debt has not been barred by any applicable law. I request payment of United States Treasury securities and/or related payments
belonging to the decedent, to the extent entitled.
4. Description of securities and/or related payments:
TITLE OF SECURITY