Form Pd F 1522 E - Special Form Of Request For Payment Of U.s. Savings And Retirement Securities

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For official use only:
Customer Name
Customer No.
SPECIAL FORM OF REQUEST FOR PAYMENT OF
PD F 1522 E
OMB No. 1535-0004
Department of the Treasury
UNITED STATES SAVINGS AND RETIREMENT
Bureau of the Public Debt
SECURITIES WHERE USE OF A DETACHED
FOR OFFICIAL USE ONLY
(Revised April 2012)
REQUEST IS AUTHORIZED
TRANSFER MONTH & YEAR ____/____
Visit us on the Web at
FISCAL AGENT CODE ______________
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
1. DESCRIPTION OF BONDS
I am the owner or person entitled to payment of the securities described below, which bear the name(s) of
.
ISSUE DATE
SERIAL NUMBER
ISSUE DATE
SERIAL NUMBER
ISSUE DATE
SERIAL NUMBER
(If you need more space, attach either a PD F 3500 [see ], a plain sheet of paper, or a photocopy.)
2. REQUEST FOR PAYMENT
a check.
I request that the described bonds be redeemed and payment be made in the form of
direct deposit.
To the extent of:
(Complete this line only if partial redemption and reissue of the remainder is desired or if the signer is entitled only to a portion of
the bonds listed. See Item 2 in the Instructions.)
(Social Security Number of Payee)
OR
(Employer Identification Number of Payee)
3. DELIVERY INSTRUCTIONS
(Read Item 3 in the Instructions before completing this section and complete only Item 3A or 3B.)
A.
Please mail my redemption check to:
(Name)
(Number and Street, Rural Route, or P.O. Box)
(City)
(State)
(ZIP Code)
B.
Please deposit my funds directly, as authorized below:
(Name/Names on the Account)
Type of Account:
Checking
Savings
(Depositor's Account No.)
Bank Routing No.:
(Financial Institution's Name)
(Phone No.)

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