Form Pd F 5180 E - Reinvestment Request - 2011

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OMB No. 1535-0069

PD F 5180 E

Department of the Treasury

Legacy Treasury Direct

Bureau of the Public Debt

(Revised May 2011)

REINVESTMENT REQUEST

800-722-2678

SEE INSTRUCTIONS - TYPE OR PRINT IN INK ONLY - NO ALTERATIONS OR CORRECTIONS

1. Legacy Treasury Direct ACCOUNT INFORMATION

You will find this information on your Statement of Account.

FOR DEPARTMENT USE

Legacy Treasury Direct ACCOUNT NUMBER

DOCUMENT AUTHORITY

ACCOUNT NAME

APPROVED BY

DATE APPROVED

CUSIP

Have You Tried Reinvest Direct ? It’s Easy!

To make a full reinvestment of your maturing securities, try our

phone (800-722-2678) or web services ( ).

2. SCHEDULING

BILL REINVESTMENT

REINVEST THE SUB-ACCOUNTS SHOWN BELOW.

REINVEST

13 WEEKS

FOR

TIMES

(Use this option ONLY when specifying SUB-ACCOUNTS.)

TERM

NUMBER OF

SUB-

AMOUNT

(13, 26)

REINVESTMENTS

ACCOUNT

FOR

26 WEEKS

TIMES

WEEKS

Note: The Department of the Treasury plans to stop purchases and reinvestments in Legacy

Treasury Direct no later than November 1, 2012.

3. CANCELING

ALL REINVESTMENTS.

REINVESTMENTS ONLY FOR THE SUB-ACCOUNTS SHOWN HERE:

4. AUTHORIZATION

I submit this request pursuant to the provisions of Department of the Treasury Circulars, Public Debt Series Nos. 2-86 (31 CFR Part 357) and 1-93 (31 CFR Part 356), and

the applicable offering announcement. Under penalties of perjury, I further certify that all other information provided on this form is true, correct and complete.

Signature(s)

Title (if appropriate)

Date

Telephone

SEE INSTRUCTIONS FOR PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE

RESET