Fs Form 1050 - Creditor'S Request For Payment Of Treasury Securities Belonging To A Decedent'S Estate Being Settled Without Administration
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For official use only:
Customer Name
Case Number
FS Form 1050 (Revised June 2016)
OMB No. 1530-0027
Creditor’s Request for Payment of Treasury
Securities Belonging to a Decedent’s Estate
Being Settled Without Administration
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.”
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.
Pay to:
(Name)
(Phone Number)
(Mailing Address)
(E-mail Address)
4. Description of securities and/or related payments:
ISSUE
TITLE OF SECURITY
FACE AMOUNT
IDENTIFYING NUMBER
REGISTRATION
DATE
FS Form 1050
Department of the Treasury | Bureau of the Fiscal Service
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