Form PD-F-2966 Special Bond of Indemnity

RESET
For official use only:
Customer Name

Customer No.

PD F 2966 E
Department of the Treasury
Bureau of the Public Debt
(Revised September 2006)

OMB No. 1535-0062

SPECIAL BOND OF INDEMNITY BY PURCHASER OF UNITED STATES
SAVINGS BONDS/NOTES INVOLVED IN A CHAIN LETTER SCHEME

IMPORTANT: Follow instructions in filling out this form. You should be aware that the making of any false, fictitious or fraudulent claim or statement to the
United States is a crime that is punishable by fine and/or imprisonment.
PRINT IN INK OR TYPE ALL INFORMATION

KNOW ALL MEN BY THESE PRESENTS, that I,
(First Name)

(Middle Name or Initial)

(Last Name)

of
(Number and Street or Rural Route)

am held and firmly bound to the United States of America in the amount
(City)

(State)

(ZIP Code)

($

of

)

(For Series E and Series I show seven times the face amount; for Series EE show four times the face amount of the savings bonds described below.)

to be paid to the United States of America; to which payment I bind myself, my heirs, legatees, executors, administrators, successors and assigns, jointly and
severally by this agreement.
WHEREAS, I present and surrender the following-described United States Savings Bonds to the United States Department of the Treasury:

ISSUE DATE

FACE AMOUNT

INSCRIPTION
(Provide complete Social Security number [for example, 12345-6789], names, including middle names or initials, and
addresses on the bonds)

BOND NUMBER

(If you need more space, use the continuation sheet on page 2.)

AND WHEREAS, I allege under penalty of perjury that I purchased these bonds with my funds with the intention of participating in a chain letter
scheme, and I later discovered that participation in such a scheme violates certain laws and regulations of the United States if the mails were used and
might violate State laws even if the mails were not used;
AND WHEREAS, under these circumstances, I do not wish to participate in the scheme and hereby request that the United States REFUND THE
PURCHASE PRICE of these bonds;
AND WHEREAS, the Secretary of the Treasury has authorized the REFUND OF THE PURCHASE PRICE of these bonds, if I furnish satisfactory
evidence that I am the purchaser of the bonds, and if I furnish a bond of indemnity without surety to the United States of America in the above amount;
NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, that if I, my heirs, legatees, executors, administrators, successors or
assigns, or any of them, will indemnify and save harmless the United States from any claim on account of these bonds and interest thereon, and from
any and all losses which the United States may sustain as a result of any such other claim, and shall repay to the United States all sums of money
which the United States may pay on the account of these bonds and interest thereon, with interest, administrative costs, and penalties, then this
obligation will be void, otherwise it will remain in full force and effect.

You must wait until you are in the presence of a certifying officer to sign this form.

Sign Here
(Signature of obligor - must agree with name in first paragraph)

(Print Name)

(Number and Street or Rural Route)

(Social Security Number)

Home Address

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

Certifying Officer – The individual must sign in your presence. Complete the certification and affix your stamp or seal.
I CERTIFY that

, whose identity is known or was

proven to me, personally appeared before me this

day of

,
(Month)

at

,
(Year)

, and signed this form.
(City)

(State)
(Signature and title of certifying officer)

(OFFICIAL STAMP
OR SEAL)

(Number and Street or Rural Route)
(City)

(State)

(ZIP Code)

Continuation of description of bonds:
ISSUE DATE

FACE AMOUNT

BOND NUMBER

INSCRIPTION
(Provide complete Social Security number [for example, 12345-6789], names, including middle names or initials, and
addresses on the bonds)

(If you need more space, use a continuation sheet and attach it to the form.)

INSTRUCTIONS
("Bonds" in these instructions refers to savings bonds, savings notes, retirement plan bonds, and individual retirement bonds.)
USE OF FORM – Use this form to apply for refund of purchase price of United States Savings Bonds purchased in connection with a chain letter
scheme.
Furnish your full name including first name, middle name or initial, and last name.
Show your complete mailing address.
Enter the amount of the bond of indemnity, in alphabetical and numerical form. The amount necessary depends on the type of bond involved.
Series EE, Series E, and Series I bonds may earn interest beyond their original maturity date. As a result, the bond of indemnity must be in an
amount four times the face amount of the Series EE bonds and seven times the face amount of the Series E and Series I bonds listed on the
form. For example, for a $50 Series EE bond, the amount must be shown as "TWO HUNDRED DOLLARS" ($200.00) and for a $50 Series E or
Series I bond, the amount must be shown as "THREE HUNDRED FIFTY DOLLARS" ($350.00).
Describe the bonds.
Sign the form, show your mailing address, social security number, and daytime telephone number. (See the next section regarding proper
certification.)
CERTIFICATION
Person Who Signs Form
• You must appear before and establish identification to the satisfaction of an authorized certifying officer and sign in the presence of that officer.
Authorized certifying officers are available at financial institutions, including credit unions, in the United States. For a complete list of such
officers, see Department of the Treasury Circulars, No. 530, and Public Debt Series Nos. 3-80 and 2-98.
Certifying Officer
• The person appearing before you must establish identification by positive and reliable evidence before this form is signed, unless he/she is
personally known to you. You must complete and sign the certification form and affix the seal or stamp required in certifying requests for
payment.
ADDITIONAL EVIDENCE
You must provide evidence that you purchased the bonds. Such evidence includes a copy of the purchase order; a statement from the issuing agent
that accepted the order; the canceled check used to purchase the bond; or a copy of the chain letter bearing your name. If the evidence shows that
someone else was the purchaser of the bonds and you obtained possession from that person, you will also be expected to furnish a notarized statement
from the original purchaser to establish the circumstances under which he/she delivered the bonds.
WHERE TO SEND – Send the PD F 2966, bonds, proof of purchase, and any other appropriate evidence, to the Department of the Treasury, Bureau

of the Public Debt, PO Box 7012, Parkersburg, WV 26106-7012.
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
We're asking for the information on this form to assist us in processing your securities transaction requests. Our authority comes from 31 U.S.C. Ch. 31 which authorizes the
Treasury Department to borrow money to pay the public debt of the United States. Also, 26 U.S.C. 6109 requires us to use your SSN on certain forms when we report
taxable income to IRS. It's voluntary that you provide the requested information, but without it, we may not be able to process your transaction requests. Information
concerning your securities holdings and transactions is considered confidential under Treasury regulations (31 CFR Part 323) and the Privacy Act. However, the following
routine uses of this information may include disclosure to the following persons or entities: agents and contractors who help us manage the public debt; others entitled to the
securities or payment; agencies (including disclosure through approved computer matches) determining eligibility for benefits, finding persons we've lost contact with, or
helping us collect debts; agencies for investigations or prosecutions; courts, counsel, and others for litigation and other proceedings; a Congressional office asking on your
behalf; and as otherwise authorized by law.
We estimate it will take you about 08 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 Public Debt, Forms Management Officer, Parkersburg,
WV 26106-1328. DO NOT SEND completed form to the above address; send to one of the Treasury Retail Securities Sites shown in "WHERE TO SEND.”

For Official Use Only

Accepted by: _____________________________________
(2)

Date: ________________