Fs Form 5336 - Disposition Of Treasury Securities Belonging To A Decedent'S Estate Being Settled Without Administration - U.s. Department Of The Treasury Page 7
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10PART D – PAYMENT TO VOLUNTARY REPRESENTATIVE
Complete this part to receive payment as voluntary representative for MATURED marketable securities or savings bonds.
A person acting as voluntary representative who receives payment of securities and/or related payments warrants, certifies, and
unconditionally guarantees that he or she will make distribution of the proceeds to the persons entitled by the law of the decedent's
domicile at the date of death. Payment to a voluntary representative is for the convenience of the United States and does not determine
ownership of the securities or their proceeds.
1. Provide your name, Social Security Number, and mailing address.
Note: Your Social Security Number may be used to report all of the interest earned to the Internal Revenue Service for Federal income
tax purposes. For Federal income tax information, see IRS Publication 550 or contact the IRS or your tax advisor.
2. Describe the securities and/or checks:
•
TITLE OF SECURITY – Identify each security by series, interest rate, type, CUSIP, and call and maturity date, as
appropriate. If describing a check, insert the word “check.”
•
ISSUE DATE – Provide the issue date of each security or check.
•
FACE AMOUNT – Provide the face amount (par or denomination) of each security or check.
•
IDENTIFYING NUMBER (if applicable) – Provide the serial number of each security, the confirmation number, or the
check number.
•
REGISTRATION – Provide the registration of each security, check, or account; also provide the account number, if any.
Note: If the Taxpayer Identification Number is included in the registration but is masked (i.e. XXX-XX-1234), please be
sure to provide the entire number.
EXAMPLES:
ISSUE
TITLE OF SECURITY
FACE AMOUNT
IDENTIFYING NUMBER
REGISTRATION
DATE
Paper Marketable Security
Serial #
9 1/8 % TREASURY BOND OF
JOHN DOE AND JANE DOE
123
5/15/79
$5,000
2004-2009 MATURES 5/15/09
SSN 222-22-2222
CUSIP 912810CG1
ACCT # 4800-123-1234
Electronic Marketable Security
JOHN DOE
2/5/04
$1,000
CUSIP 912795QW4
SSN 222-22-2222
Confirmation #
ACCT # N-111-11-1111
Electronic Series I Savings Bond
1/1/02
$100
IAAAB
SERIES I
JOHN DOE
SSN 222-22-2222
Serial #
Paper Series EE Savings Bond
7/99
$100
JOHN DOE
C-123,456,789-EE
SERIES EE
OR JANE DOE
Check #
Check
7/26/04
$351.02
JOHN DOE
502123456
CHECK
If unsure what to provide in each of the areas, furnish all identifying information in the space for REGISTRATION.
3. Payment for savings bonds (paper or electronic) and matured electronic marketable securities will be made by direct deposit. To
receive payment for these securities, please provide the requested information. If you don’t know the routing number of your financial
institution, the financial institution can give it to you.
Payment for paper marketable securities will be made by check. (This does NOT include savings bonds. Payment for savings bonds will
be made by direct deposit.)
(If you completed Part D to receive payment as voluntary representative, do not complete Part E or F; skip to Part G.)
FS Form 5336
Department of the Treasury | Bureau of the Fiscal Service
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