Form 5394 - Agreement And Request For Disposition Of A Decedent'S Treasury Securities
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For official use only:
Customer Name
Case Number
FS Form 5394 (revised February 2017)
OMB No. 1530-0046
Agreement and Request for Disposition
of a Decedent’s Treasury Securities
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
USE OF FORM – Use this form to request disposition of United States Treasury Securities (Treasury Bills, Notes, Bonds, TIPS,
Floating Rate Notes, Savings Bonds, and Savings Notes) and/or related payments belonging to a decedent’s estate, but only
under one of the circumstances described in the instructions.
NOTE: When we reissue a Series EE or Series I savings bond, we no longer provide a paper bond. The reissued bond
is in electronic form, in our online system TreasuryDirect. For information on opening an account in TreasuryDirect, go to
PART A – DECEDENT’S 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)
(State of Legal Residence)
PART B – CIRCUMSTANCES OF REQUEST
Mark the appropriate box to indicate the circumstances under which you are using this form. See Part B of the instructions for evidence
requirements.
1.
This request is made in connection with an estate that has been administered, the legal representative discharged, and the
estate closed. Evidence – A certified copy of the final account or decree of distribution.
2.
This request is made in connection with an estate that is being settled in accordance with State statute (for example: Summary
Administration, Small Estates Act, Texas Muniment of Title, or Louisiana Judgment of Possession). Evidence – Submit
evidence in accordance with state law or statute.
PART C – PERSONS ENTITLED
Complete this Part to show all persons entitled to the securities and/or related payments.
1. List the persons entitled to the securities and/or payments (according to the supporting evidence):
Age
Name
Basis of Entitlement
(if under 21)
2. List persons from Item 1 who are under legal disability (if any):
Name
Legal Disability
Name and Address of Representative
Capacity
FS Form 5394
Department of the Treasury | Bureau of the Fiscal Service
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