Form 5394 - Agreement And Request For Disposition Of A Decedent'S Treasury Securities Page 9
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93.
Check the appropriate block indicating type of distribution for the particular type of security involved. Securities can’t be
transferred from one type to another. Eligible securities can be transferred within Legacy Treasury Direct, but not into Legacy
Treasury Direct from outside Legacy Treasury Direct. Provide account numbers, if any.
• Provide a separate Part D for each different registration or type of distribution desired.
• In certain circumstances, we may need to request additional forms and/or information in order to complete the requested
action. In this event, we will provide any additional forms and/or instructions.
• Reissue or transfer (when applicable) isn't an option if there is not sufficient time to process the transaction before the
security matures. If we are unable to process a reissue or transfer request before the security matures, payment will be
issued. All Saving Bonds of Series A, B, C, D, E, F, G, H, J, and K, and all Savings Notes, have reached final maturity.
• Any interest that is due or becomes due on securities belonging to the estate of the decedent will be paid to the person to
whom the securities are distributed, unless otherwise requested.
4.
Provide your mailing address.
5.
Provide your e-mail address.
6.
Provide information on the bank account where the payment is to be direct-deposited. All persons requesting payment must
sign in Part E of this form. If payment is to be deposited to a bank account in the name of a different person, then that person
or his or her representative, who can authorize such a deposit, must also sign in Part E.
PART E – SIGNATURES AND CERTIFICATIONS
SIGNATURES – The application must be signed in ink by:
•
All competent persons listed in Part C, Item 1, and Part D, Item 1.
•
The legal guardian or similar representative of the estate of any person under legal disability listed in Part C, Item 2, or
Part D, Item 1; and
•
A parent on behalf of any minor listed in Part C, Item 1, or Part D, Item 1.
CERTIFICATION – Each person whose signature is required must appear before and establish identification to the satisfaction of
an authorized certifying individual. The signatures to the form must be signed in the certifying individual’s presence. The
certifying individual must affix the seal or stamp which is used when certifying requests for payment. Authorized certifying
individuals are available at most banking institutions, including credit unions.
Certification by a notary isn’t acceptable. Examples of
cceptable seals and stamps:
a
•
The financial institution’s official seal or stamp, including:
Signature Guaranteed seal or stamp; Endorsement
Guaranteed seal or stamp; Corporate seal or stamp (a corporate resolution isn’t required); or Issuing or paying agent seal
or stamp (including name, location, and four-digit identification number or nine-digit routing number).
•
The seal or stamp of Treasury-recognized Signature Guarantee Programs or other Treasury-approved Medallion
Programs.
ADDITIONAL EVIDENCE – The Commissioner of the Fiscal Service, as designee of the Secretary of the Treasury, reserves the
right in any particular case to require the submission of additional evidence.
WHERE TO SEND –
Send this form (without instruction pages), send all securities and/or related checks, and send any necessary
evidence to the Treasury Retail Securities Site, using the appropriate address below. Legal evidence or documentation you submit
cannot be returned.
•
H or HH Savings Bonds: PO Box 2186, Minneapolis, MN 55480-2186.
•
E, EE, or I Savings Bonds–paper: PO Box 214, Minneapolis, MN 55480-0214.
•
E, EE, or I Savings Bonds–electronic: PO Box 7015, Minneapolis, MN 55480-7015.
•
Treasury Bills, Notes, Bonds, or TIPS: PO Box 9150, Minneapolis, MN 55480-9150.
NOTICE UNDER PRIVACY ACT AND PAPERWORK REDUCTION ACT
The collection of the information you are requested to provide on this form is authorized by 31 U.S.C. CH. 31 relating to the public debt of the
United States. The furnishing of a Social Security Number, if requested, is also required by Section 6109 of the Internal Revenue Code (26
U.S.C. 6109).
The purpose of requesting the information is to enable the Bureau of the Fiscal Service and its agents to issue securities, process transactions,
make payments, identify owners and their accounts, and provide reports to the Internal Revenue Service. Furnishing the information is voluntary;
however, without the information, the Fiscal Service may be unable to process transactions.
Information concerning securities holdings and transactions is considered confidential under Treasury regulations (31 CFR, Part 323) and the
Privacy Act. This information may be disclosed to a law enforcement agency for investigation purposes; courts and counsel for litigation
purposes; others entitled to distribution or payment; agents and contractors to administer the public debt; agencies or entities for debt collection
or to obtain current addresses for payment; agencies through approved computer matches; Congressional offices in response to an inquiry by
the individual to whom the record pertains; as otherwise authorized by law or regulation.
We estimate it will take you about 30 minutes to complete this form. However, you are not required to provide information requested unless a
valid OMB control number is displayed on the form. Any comments or suggestions regarding this form should be sent to the Bureau of the Fiscal
Service, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND your completed form to this address; send it to the
appropriate address in "WHERE TO SEND" in the Instructions.
FS Form 5394
Department of the Treasury | Bureau of the Fiscal Service
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