Form Pd F 4000 E - Request To Reissue United States Savings Bonds Page 3
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6Reserved for Identification Notations
Customer Account Number
Customer Account Number
and Date Established:
and Date Established:
_________________________________
_________________________________
Identified by:
Identified by:
_________________________________________
_________________________________________
Documents – Descriptions:
Documents – Descriptions:
____________________________
____________________________
INSTRUCTIONS TO CERTIFYING OFFICER
Each person appearing before you must establish identification by positive and reliable evidence before this form is signed,
unless he or she is personally known to you. You must place an adequate notation in the area reserved for identification
notations in Part C or on a separate record, showing exactly how identification was established. A notation is adequate if it is
sufficiently detailed to permit, at a later date, a determination of the exact identification actually used. You and, if you are an
officer or employee of an organization, the organization will be held fully responsible for the adequacy of the identification.
The signatures to the request must be executed in your presence. Fully complete and sign the certification form provided for
your use for each signature you witness.
If you are an employee (rather than an officer) authorized to certify signatures, insert the words “Authorized Signature” in the
space provided for the title. Insert the place and date, as required on the form, and impress the seal of your organization.
FOR FEDERAL RESERVE BANK USE ONLY
This transaction was a reportable event.
$
was reported under
for
.
(Social Security Number)
(Year)
This transaction was not a reportable event. No interest was reported.
TAX LIABILITY: If the name of a living owner or principal coowner of the bonds is eliminated from the registration, the owner or
principal coowner must include the interest earned and previously unreported on the bonds to the date of the transaction on his or her
Federal income tax return for the year of the reissue. (Both registrants are considered to be coowners when bonds are registered in the
form: "A" or "B.") The principal coowner is the coowner who (1) purchased the bonds with his or her own funds, or (2) received them
as a gift, inheritance, or legacy, or as a result of judicial proceedings, and had them reissued in coownership form, provided he or she
has received no contribution in money or money's worth for designating the other coowner on the bonds. If the reissue is a reportable
event, the interest earned on the bonds to the date of the reissue will be reported to the Internal Revenue Service (IRS) by a Federal
Reserve Bank or Branch or the Bureau of the Public Debt under the Tax Equity and Fiscal Responsibility Act of 1982.
THE
OBLIGATION TO REPORT THE INTEREST CANNOT BE TRANSFERRED TO SOMEONE ELSE THROUGH A REISSUE
TRANSACTION. If you have any questions concerning the tax consequences, consult the IRS, or write to the Commissioner of Internal
Revenue, Washington, DC 20224. Unless we are otherwise informed, the first-named coowner will be considered the principal
coowner for the purpose of this transaction.
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PD F 4000
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