Form 5394 - Agreement And Request For Disposition Of A Decedent'S Treasury Securities Page 6
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9Instructions to Certifying Individual: 1. Name of 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. NOTE: For more than three signatures, use the next page too.
I CERTIFY that
, whose identity is known or was
(Name of Person Who Appeared)
,
proven to me, personally appeared before me this
day of
(Month / Year)
at
, and signed this form.
(City / State)
(Signature and Title of Certifying Individual)
(OFFICIAL STAMP
OR SEAL)
(Name of Financial Institution)
(Address)
(City / State / ZIP Code)
(Telephone)
I CERTIFY that
, whose identity is known or was
(Name of Person Who Appeared)
,
proven to me, personally appeared before me this
day of
(Month / Year)
at
, and signed this form.
(City / State)
(Signature and Title of Certifying Individual)
(OFFICIAL STAMP
OR SEAL)
(Name of Financial Institution)
(Address)
(City / State / ZIP Code)
(Telephone)
I CERTIFY that
, whose identity is known or was
(Name of Person Who Appeared)
,
proven to me, personally appeared before me this
day of
(Month / Year)
at
, and signed this form.
(City / State)
(Signature and Title of Certifying Individual)
(OFFICIAL STAMP
OR SEAL)
(Name of Financial Institution)
(Address)
(City / State / ZIP Code)
(Telephone)
FS Form 5394
Department of the Treasury | Bureau of the Fiscal Service
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