Form 5394 - Agreement And Request For Disposition Of A Decedent'S Treasury Securities Page 5
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9PART E - SIGNATURES AND CERTIFICATIONS
The undersigned certify under penalty of perjury that the information provided herein is true and correct to the best of our
knowledge and belief and agree to distribution of the securities as indicated in Part D. We bind ourselves, our heirs, legatees,
successors and assigns, jointly and severally, to hold the United States harmless on account of the transaction requested, to indemnify
unconditionally and promptly repay the United States in the event of any loss which results from this request, including interest,
administrative costs, and penalties. We consent to the release of any information regarding this transaction, including information
contained in this application, to any party having an ownership or entitlement interest in the securities or payments.
You must wait until you are in the presence of a certifying officer to sign this form.
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Address:
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(City)
(State)
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E-Mail Address:
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Person to contact if additional information is necessary:
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FS Form 5394
Department of the Treasury | Bureau of the Fiscal Service
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