4. SIGNATURE
(You must wait until you’re in the presence of a certifying officer to sign this form.)
I ratify any and all authorized transactions by my attorney-in-fact.
Sign Here:
(Signature of Grantor)
(Print Name)
Home Address:
(Number and Street, Rural Route, or PO Box)
(City)
(State)
(ZIP Code)
(Taxpayer Identification Number)
(Account Number, if applicable)
E-Mail Address:
(Daytime Telephone Number)
(Optional)
Instructions to Certifying Officer:
1. Name of the person(s) who appeared and date of appearance MUST be completed.
2. Medallion stamps require an original signature.
3. Person(s) must sign in your presence.
I certify that
, whose identity(ies) is/are known or
(Name[s] of Person[s] Who Appeared)
proven to me, personally appeared before me this
day of
,
(Month and Year)
at
, and signed this form.
(City, State)
(Signature and Title of Certifying Officer)
(OFFICIAL STAMP OR SEAL)
(Name of Financial Institution)
(Address)
ACCEPTABLE CERTIFICATIONS:
Financial Institution's Official Seal or Stamp
(such as Corporate Seal, Signature Guaranteed
(City/State/ZIP Code)
Stamp, or Medallion Stamp). Brokers must
use a Medallion Stamp.
(Notary certification is NOT acceptable.)
(Telephone)
INSTRUCTIONS
USE OF FORM – Use this form to appoint and authorize an attorney-in-fact to conduct any and all authorized transactions
regarding Treasury securities. These securities include, but are not necessarily limited to, Treasury bills, notes, bonds, and
TIPS, and all series of United States Savings Bonds and Savings Notes. Authorized transactions include, but are not
limited to, changes of payment information, collection of interest, redemptions, transfers, assignments, purchases by ACH
®
(PayDirect
) or any other authorized payment method, reinvestments, and/or the completion of tax documents. (An
attorney-in-fact may not reissue definitive savings bonds.)
IMPORTANT NOTICES
•
This form gives the individual or organization you name as attorney-in-fact broad powers to handle your securities
and/or securities for which you are acting on the owner's or entitled party's behalf as fiduciary. If you have questions
about these powers, you should seek professional legal advice before signing this form.
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