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For official use only:

Customer Name

Customer No.

PD F 1050 E

CREDITOR'S CONSENT TO DISPOSITION OF

OMB No. 1535-0055

Department of the Treasury

UNITED STATES SECURITIES AND RELATED CHECKS

Bureau of the Public Debt

WITHOUT ADMINISTRATION OF DECEASED OWNER'S ESTATE

(Revised December 2001)

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

Federal Reserve Bank

TO:

Bureau of the Public Debt, Office of Investor Services, PO Box 1328, Parkersburg, WV 26106-1328

The following consent applies to the estate of

deceased.

(Name of Decedent)

I certify that

(Name of Person, Firm, or Corporation)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

is/was a creditor of the estate of the above-named decedent on account of (state nature of claim):

that the total amount of such claim was $

, of which $

has been paid by

;

that the remainder has not been paid and is still justly due and owing to the above-named creditor; and that I on behalf of

that creditor consent to the transfer, reissue, exchange, or payment to or for the account of any other person, of all

United States securities registered in the name of, or assigned to, or otherwise belonging to the decedent, and checks

issued in payment of such securities or interest thereon.

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)

* If a firm or corporation having no seal,

so state:__________________

(Signature and title of officer of organizational creditor)

I CERTIFY that

, whose identity is well-known or

proved to me, personally appeared before me this

day of

(Month)

(Year)

, and signed the above consent.

(City)

(State)

(OFFICIAL STAMP

(Signature and title of certifying officer)

OR SEAL)

(Street address)

My commission expires

(For notaries only)

(City)

(State)

(ZIP Code)

IDENTIFICATION NOTATIONS

Customer Account Number

and Date Established:

Documents - Description:

Identified by (Signature and Address):

INSTRUCTIONS TO CERTIFYING OFFICER

Each person appearing before you must establish identification by positive and reliable evidence before this form is signed, unless he or she is

personally well-known to you. You must place an adequate notation above or on a separate record, showing exactly how identification was established.

A notation is adequate if it is sufficiently detailed to permit, at a later date, a determination of the exact identification actually used. You and, if you are

an officer or employee of an organization, the organization will be held fully responsible for the adequacy of the identification.

The signatures to the request must be executed in your presence. Fully complete and sign the certification form provided for your use for each signature

you witness. If you are an employee (rather than an officer) authorized to certify signatures, insert the words “Authorized Signature” in the space

provided for the title. Insert the place and date, as required on the form, and impress the seal of your organization.