Fs Form 5511 - Transfer Request Page 5
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7I 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 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.)
INSTRUCTIONS
No. 1
ACCOUNT INFORMATION
TreasuryDirect Account Information – Provide the TreasuryDirect Account Number, TreasuryDirect Account Name, and
Taxpayer Identification Number (Social Security Number or Employer Identification Number). When transferring securities from a
custom, minor, or conversion linked account, provide the account information of the linked account.
No. 2
DESCRIPTION OF SECURITIES
To transfer . . .
Then . . .
ALL securities in the account described in
Select the first square.
Item 1
Securities described on an attached list
Select the second square and attach the printed list from
your TreasuryDirect account.
Less than ALL securities in the account,
Select the third square and complete the table to include
or if not attaching a list
the Confirmation Number, Issue Date, Face Amount
(principal amount for savings bonds or par amount for bills,
notes, bonds, FRNs, TIPS), and CUSIP Number (for bills,
notes, bonds, FRNs, TIPS).
Indicate either a FULL or
partial transfer. If you do not indicate a partial transfer,
we will assume transfer in FULL.
NOTE: If you are requesting transfer of savings bonds to a trust, carefully read and complete Page 2.
FS Form 5511
Department of the Treasury | Bureau of the Fiscal Service
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