Form 5394 - Agreement And Request For Disposition Of A Decedent'S Treasury Securities Page 8
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9PART B – CIRCUMSTANCES OF REQUEST
Mark the appropriate box to indicate the circumstances under which you are using this form.
•
Mark box 1 if the estate has been settled through court proceedings and the legal representative is no longer
acting.
•
Mark box 2 if the estate 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 Requirements:
If the estate is closed, submit a certified copy under court seal of the final account or decree of distribution, if any.
If the estate is being settled in accordance with State statute, submit the original or a copy, certified under court seal (if filed
with the court), of the evidence making distribution of the securities and/or payments or establishing your authority to collect the
proceeds of the estate in accordance with the State law or statute.
PART C – PERSONS ENTITLED
List all persons entitled to collect the securities and/or payments through the decedent’s estate, as established in the
supporting evidence.
1.
Show each entitled person’s name, the basis of his or her entitlement (i.e., “legatee,” “surviving spouse,” etc.), and, if he
or she is under 21,
his or her age.
2.
Show any of the persons listed in Item 1 who are under a legal disability. In the space for “Legal Disability,” enter the
nature of the disability, such as the individual is an “incapacitated person.” If the court appointed a legal representative,
show the legal representative’s name and address. In the space for “Capacity,” enter the official title or description of the
representative acting, for example, “legal guardian” or “conservator.” The representative must submit a certified copy
under court seal of the letters of appointment dated within one year of submission.
PART D – DISPOSITION OF SECURITIES AND PAYMENTS TO PERSONS ENTITLED
1. Enter the name of only one entitled person in each Part D, Item 1. (A separate Part D must be completed for each person
entitled and each type of distribution desired.) Enter the appropriate Social Security or Employer Identification Number.
2. Describe only the securities or checks to which the person shown in Item 1 is entitled.
•
TITLE OF SECURITY – Identify each security by series, interest rate, type, CUSIP, call and maturity date, as appropriate. If
describing a check, insert the word “check.”
•
ISSUE DATE – Provide the issue date of each security or check.
•
FACE AMOUNT – Provide the face amount (par or denomination) of each security or check.
•
IDENTIFYING NUMBER
– Provide the serial number of each security, the confirmation number, or the check
(if applicable)
number.
•
REGISTRATION – Provide the registration of each security, check, or account; also provide the account number, if any.
Note: If the Taxpayer Identification Number is included in the registration but is masked (i.e. ***-**-1234), please be sure
to provide the entire number.
EXAMPLES:
ISSUE
TITLE OF SECURITY
FACE AMOUNT
IDENTIFYING NUMBER
REGISTRATION
DATE
Paper Marketable Security
Serial #
9 1/8 % TREASURY BOND OF
JOHN DOE AND BOB DOE
5/15/79
$5,000
123
2004-2009 MATURES 5/15/09
SSN 222-22-2222
CUSIP 912810CG1
ACCT # 4800-123-1234
Electronic Marketable Security
2/5/04
$1,000
JIM DOE
CUSIP 912795QW4
SSN 222-22-2222
Confirmation #
ACCT # N-111-111-111
Electronic Series I Savings Bond
1/1/02
$100
12345
SERIES I
BOB SMITH
SSN 222-22-2222
Serial #
Paper Series EE Savings Bond
7/99
$100
BILL SMITH
SERIES EE
C-123,456,789-EE
OR JANE SMITH
Check #
Check
7/26/04
$351.02
JIM SMITH
502123456
CHECK
If unsure what to provide in each of the areas, furnish in the space for "REGISTRATION" all information shown on the face of the security or check.
NOTE: Individual savings bonds (Series EE, E, I, HH, and H) may not be split. Each savings bond must be distributed, in its entirety, to
an entitled individual or entity. Marketable securities may be distributed in full or in increments of $100. If you want to split a
marketable security, describe the exact amount of the distribution.
FS Form 5394
Department of the Treasury | Bureau of the Fiscal Service
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