Fs Form 5511 - Transfer Request Page 4
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7SIGNATURES AND CERTIFICATIONS
Under penalties of perjury, I/we certify that the information provided on this form is true, correct, and complete. This request is
submitted pursuant to the applicable provisions of 31 CFR Parts 353, 356, 357, 360, and 363. I/we agree to indemnify and hold
the United States harmless in the event of any loss that results from this request.
You must wait until you are in the presence of a certifying officer to sign this form.
Certifying officers are available at banks, trust companies, and credit unions.
Certification by a notary public is NOT acceptable.
Sign Here:
(Signature)
(Daytime Telephone No.)
(Mailing Address)
(E-mail Address)
Sign Here:
(Signature)
(Daytime Telephone No.)
(Mailing Address)
(E-mail Address)
Instructions to Certifying Officer:
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: To certify a second signature, use the next page.
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)
, and signed this form.
at
(City, State)
(Signature and Title of Certifying Officer)
(OFFICIAL STAMP
(Name of Financial Institution)
OR SEAL)
(Address)
(City, State, ZIP Code)
ACCEPTABLE CERTIFICATIONS:
Financial institution's
official seal or stamp (such as corporate seal, signature
guaranteed stamp, or medallion stamp).
(Telephone)
(Notary certification is NOT acceptable.)
FS Form 5511
Department of the Treasury | Bureau of the Fiscal Service
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