Form Pd F 1050 E - Creditor'S Request For Payment Of Treasury Securities Belonging To A Decedent'S Estate Being Settled Without Administration Page 2

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PART C - SIGNATURE AND CERTIFICATION

I certify under penalty of perjury that the information provided herein is true and correct to the best of my knowledge and belief. The

United States is not liable to any person for the improper payment of securities. I bind myself, my 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 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.

(SEAL)*

(Signature of individual creditor or name of organizational creditor)

* There is no seal

(Signature and title of officer of organizational creditor)

Instructions to Certifying Officer:

1. Name of the person(s) who appeared and date of appearance MUST be completed.

2. Medallion stamps require an original signature.

3. Person(s) must sign in your presence.

I certify that

, whose identity(ies) is/are known or

(Name[s] of Person[s] Who Appeared)

proven to me, personally appeared before me this

day of

(Month/Year)

, and signed this form.

(City, State)

(Signature and Title of Certifying Officer)

(OFFICIAL STAMP OR SEAL)

(Name of Financial Institution)

ACCEPTABLE CERTIFICATIONS:

(Address)

Financial Institution's Official Seal or Stamp

(such as Corporate Seal, Signature Guaranteed

Stamp, or Medallion Stamp). Brokers must

(City/State/ZIP Code)

use a Medallion Stamp.

(Notary certification is NOT acceptable.)

(Telephone)

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 06 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 the above address; send to the address shown in the

instructions.