Form 5394 - Agreement And Request For Disposition Of A Decedent'S Treasury Securities Page 7
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9I 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)
INSTRUCTIONS
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, under either
of the following circumstances:
•
The estate was formally administered through the court and has been closed.
•
The estate is being settled in accordance with State statute such as Summary Administration, Small Estates
Acts, Texas Muniment of Title, Louisiana Judgment of Possession, etc., without the necessity of the court
appointing an administrator, executor, or similar legal representative.
ATTACHMENTS – If you need more space for any item, use a plain sheet of paper or make a photocopy of the relevant section,
and attach to the form.
PART A – DECEDENT’S INFORMATION
Provide the requested information regarding the decedent. If more than one deceased person is named on the securities,
provide the information for the person who died last.
Insert the following information: the decedent’s name, the decedent’s Social Security Number, the state of the decedent’s last
legal residence
Submit certified copies of the death certificates for all deceased registrants.
FS Form 5394
Department of the Treasury | Bureau of the Fiscal Service
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