Form PD-F-5394 Agreement and request for disposition of a decedent's tr

RESET
For official use only:
Customer Name

Customer No.

PD F 5394 E
Department of the Treasury
Bureau of the Public Debt
(Revised July 2005)

OMB No. 1535-0131

AGREEMENT AND REQUEST FOR DISPOSITION
OF A DECEDENT'S TREASURY SECURITIES
Visit us on the Web at www.treasurydirect.gov

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

USE OF FORM – Use this form to request disposition of United States Treasury Securities (Treasury Bills, Notes, Bonds, TIPS,
Savings Bonds, and Savings Notes) and/or related payments belonging to a decedent’s estate, but only under one of the
circumstances described in the instructions.
WHERE TO SEND – Send this form, all securities and/or related checks, and any necessary evidence to the Department of the Treasury,
Bureau of the Public Debt, using the address listed below that is appropriate to the type of security involved:
HH/H (paper) Savings Bonds – PO Box 2186, Parkersburg, WV 26106-2186
E/EE/I (paper) Savings Bonds – PO Box 7012, Parkersburg, WV 26106-7012
E, EE, and I Book-Entry (electronic) Savings Bonds – PO Box 7015, Parkersburg, WV 26106-7015
Treasury Bills, Notes, Bonds, and TIPS (paper and electronic issues) - PO Box 426, Parkersburg, WV 26106-0426
Carefully read the instructions before completing this form.

PART A – DECEDENT’S INFORMATION
Provide the information below and submit certified copies of the death certificates for all deceased registrants.
(NAME OF DECEASED OWNER - If more than one person named on the securities, the person who died last)

(Decedent’s Social Security Number)

(State of Legal Residence)

PART B – CIRCUMSTANCES OF REQUEST
Mark the appropriate box to indicate the circumstances under which you are using this form. See Part B of the instructions for evidence
requirements.
1.

This request is made in connection with an estate that has been administered, the legal representative discharged, and the
estate closed. Evidence – A certified copy of the final account or decree of distribution.

2.

This request is made in connection with an estate that is being settled in accordance with State statute (for example: Summary
Administration, Small Estates Act, Texas Muniment of Title, or Louisiana Judgment of Possession). Evidence – Submit
evidence in accordance with state law or statute.

PART C – PERSONS ENTITLED
Complete this Part to show all persons entitled to the securities and/or related payments.
1. List the persons entitled to the securities and/or payments (according to the supporting evidence):
Name

Basis of Entitlement

Age
(if under 21)

2. List persons from Item 1 (if any) who are under legal disability:
Name

Legal Disability

Name and Address of Representative

Capacity

PART D – DISPOSITION OF SECURITIES AND PAYMENTS TO PERSONS ENTITLED
We are the person(s) entitled to the decedent’s estate and request and agree to distribution of the decedent's securities and/or checks as follows.

1. Distribute to:
(Name of Entitled Person)
OR
(Social Security Number)

(Employer Identification Number)

2. Description of securities and/or payments:
ISSUE
DATE

TITLE OF SECURITY

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

In full

3. Extent of distribution:

(Amount/Fractional Share/ or Percentage)

4. Type of distribution:
NOTE: Choose the option for the particular type of security involved; securities can’t be transferred from one type to another.
Complete a separate Part D for each different registration or type of distribution desired.
Savings Bonds or Notes (paper issue)

Book-Entry Savings Bonds (electronic issue)

(Series A-D, E, EE, F, G, H, HH, I, J, & K)

(Series E, EE and I)

Payment by check

Payment by Direct Deposit

Payment by Direct Deposit

Transfer to TreasuryDirect® Account Number

Conversion to Electronic Issue (Same Series)

Marketable Treasury Bills, Notes, Bonds, and TIPS (paper or electronic issue)

Reissue in single owner form
Reissue with a coowner *

Transfer unmatured securities to a new or
existing TreasuryDirect Account Number

Reissue with a beneficiary *

Transfer unmatured securities to a Commercial Book-Entry Account
Sell the unmatured security

* Name of Coowner/Beneficiary:

Payment of the matured Book-Entry or definitive security (by check)
Payment of the matured Book-Entry security (by Direct Deposit)
5. Mailing address:

6. Direct Deposit funds as authorized below:
(Name/Names on the Account)
Type of Account:

Checking

Savings

(Depositor's Account No.)
Bank Routing No.:

–

–

(Financial Institution's Name)

(Phone No.)

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PD F 5394

PART D – DISPOSITION OF SECURITIES AND PAYMENTS TO PERSONS ENTITLED (Continued)
1. Distribute to:
(Name of Entitled Person)
OR
(Social Security Number)

(Employer Identification Number)

2. Description of securities and/or payments:
ISSUE
DATE

TITLE OF SECURITY

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

In full

3. Extent of distribution:

(Amount/Fractional Share/ or Percentage)

4. Type of distribution:
NOTE: Choose the option for the particular type of security involved; securities can’t be transferred from one type to another.
Complete a separate Part D for each different registration or type of distribution desired.
Savings Bonds or Notes (paper issue)

Book-Entry Savings Bonds (electronic issue)

(Series A-D, E, EE, F, G, H, HH, I, J, & K)

(Series E, EE and I)

Payment by check

Payment by Direct Deposit

Payment by Direct Deposit

Transfer to TreasuryDirect® Account Number

Conversion to Electronic Issue (Same Series)

Marketable Treasury Bills, Notes, Bonds, and TIPS (paper or electronic issue)

Reissue in single owner form
Reissue with a coowner *

Transfer unmatured securities to a new or
existing TreasuryDirect Account Number

Reissue with a beneficiary *

Transfer unmatured securities to a Commercial Book-Entry Account
Sell the unmatured security

* Name of Coowner/Beneficiary:

Payment of the matured Book-Entry or definitive security (by check)
Payment of the matured Book-Entry security (by Direct Deposit)
5. Mailing address:

6. Direct Deposit funds as authorized below:
(Name/Names on the Account)
Type of Account:

Checking

Savings

(Depositor's Account No.)
Bank Routing No.:

–

–

(Financial Institution's Name)

(Phone No.)

(3)

PD F 5394

PART D – DISPOSITION OF SECURITIES AND PAYMENTS TO PERSONS ENTITLED (Continued)
1. Distribute to:
(Name of Entitled Person)
OR
(Social Security Number)

(Employer Identification Number)

2. Description of securities and/or payments:
ISSUE
DATE

TITLE OF SECURITY

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

In full

3. Extent of distribution:

(Amount/Fractional Share/ or Percentage)

4. Type of distribution:
NOTE: Choose the option for the particular type of security involved; securities can’t be transferred from one type to another.
Complete a separate Part D for each different registration or type of distribution desired.
Savings Bonds or Notes (paper issue)

Book-Entry Savings Bonds (electronic issue)

(Series A-D, E, EE, F, G, H, HH, I, J, & K)

(Series E, EE and I)

Payment by check

Payment by Direct Deposit

Payment by Direct Deposit

Transfer to TreasuryDirect® Account Number

Conversion to Electronic Issue (Same Series)

Marketable Treasury Bills, Notes, Bonds, and TIPS (paper or electronic issue)

Reissue in single owner form
Reissue with a coowner *

Transfer unmatured securities to a new or
existing TreasuryDirect Account Number

Reissue with a beneficiary *

Transfer unmatured securities to a Commercial Book-Entry Account
Sell the unmatured security

* Name of Coowner/Beneficiary:

Payment of the matured Book-Entry or definitive security (by check)
Payment of the matured Book-Entry security (by Direct Deposit)
5. Mailing address:

6. Direct Deposit funds as authorized below:
(Name/Names on the Account)
Type of Account:

Checking

Savings

(Depositor's Account No.)
Bank Routing No.:

–

–

(Financial Institution's Name)

(Phone No.)

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PD F 5394

PART E - SIGNATURES AND CERTIFICATIONS
The undersigned certify under penalty of perjury that the information provided herein is true and correct to the best of our
knowledge and belief and agree to distribution of the securities as indicated in Part D. We bind ourselves, our heirs, legatees,
successors and assigns, jointly and severally, to hold the United States harmless on account of the transaction requested, to indemnify
unconditionally and promptly repay the United States in the event of any loss which results from this request, including interest,
administrative costs, and penalties. We consent to the release of any information regarding this transaction, including information
contained in this application, to any party having an ownership or entitlement interest in the securities or payments.
You must wait until you are in the presence of a certifying officer to sign this form.

Sign Here: ⇒
(Applicant's Signature)
(Applicant's
Signature)

(Daytime Telephone Number)

Address:
(Number and Street, Rural Route, or PO Box)

(City)

(State)

(ZIP Code)

E-Mail Address:
Sign Here: ⇒
(Applicant's Signature)
Signature)
(Applicant's

(Daytime Telephone Number)

Address:
(Number and Street, Rural Route, or PO Box)

(City)

(State)

(ZIP Code)

E-Mail Address:
Sign Here: ⇒
(Applicant's Signature)
(Applicant's
Signature)

(Daytime Telephone Number)

Address:
(Number and Street, Rural Route, or PO Box)

(City)

(State)

(ZIP Code)

E-Mail Address:
Sign Here: ⇒
(Applicant's Signature)
(Applicant's
Signature)

(Daytime Telephone Number)

Address:
(Number and Street, Rural Route, or PO Box)

(City)

(State)

(ZIP Code)

E-Mail Address:
Sign Here: ⇒
(Applicant's Signature)
(Applicant's
Signature)

(Daytime Telephone Number)

Address:
(Number and Street, Rural Route, or PO Box)

(City)

(State)

(ZIP Code)

E-Mail Address:

Person to contact if additional information is necessary:
(Name, Daytime Telephone Number, and E-Mail Address, if applicable)

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PD F 5394

Certifying Officer - The individuals must sign in your presence. You must 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)

(Year)

, and signed this form.

at
(City)

(State)
(Signature and title of certifying officer)

(OFFICIAL STAMP
OR SEAL)

(Number and Street or Rural Route)
(City)

(State)

I CERTIFY that

(ZIP Code)

, whose identity is known or was

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
OR SEAL)

(Number and Street or Rural Route)
(City)

(State)

I CERTIFY that

(ZIP Code)

, whose identity is known or was

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
OR SEAL)

(Number and Street or Rural Route)
(City)

(State)

I CERTIFY that

(ZIP Code)

, whose identity is known or was

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
OR SEAL)

(Number and Street or Rural Route)
(City)

(State)

I CERTIFY that

(ZIP Code)

, whose identity is known or was

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
OR SEAL)

(Number and Street or Rural Route)
(City)

(6)

(State)

(ZIP Code)

PD F 5394

INSTRUCTIONS
USE OF FORM – Use this form to request disposition of United States Treasury Securities (Treasury Bills, Notes, Bonds, TIPS,
Savings Bonds, and Savings Notes) and/or related payments belonging to a decedent’s estate, under the following
circumstances:
The estate was formally administered through the court and has been closed.
The estate is being settled in accordance with State statute such as Summary Administration, Small Estates
Acts, Texas Muniment of Title, Louisiana Judgment of Possession, etc., without the necessity of the court
appointing an administrator, executor, or similar legal representative.
ATTACHMENTS – If more space is needed for any item, use a plain sheet of paper or make photocopies, as necessary, and attach to the form.

PART A – DECEDENT’S INFORMATION
Provide the requested information regarding the decedent. If more than one deceased person is named on the securities,
provide the information for the person who died last.
Insert the following information:
The decedent’s name
The decedent’s Social Security Number
The state of the decedent’s last legal residence
Submit certified copies of the death certificates for all deceased registrants.

PART B – CIRCUMSTANCES OF REQUEST
Mark the appropriate box to indicate the circumstances under which you are using this form.
Mark box 1 if the estate has been settled through court proceedings and the legal representative is no longer
acting.
Mark box 2 if the estate is being settled in accordance with State statute (for example: Summary Administration,
Small Estates Act, Texas Muniment of Title, or Louisiana Judgment of Possession).
Evidence Requirements:
If the estate is closed, submit a certified copy under court seal of the final account or decree of distribution, if any.
If the estate is being settled in accordance with State statute, submit the original or a copy, certified under court seal (if filed
with the court), of the evidence making distribution of the securities and/or payments or establishing your authority to collect the
proceeds of the estate in accordance with the State law or statute.

PART C – PERSONS ENTITLED
List all persons entitled to collect the securities and/or payments through the decedent’s estate, as established in the
supporting evidence.
1. Show each entitled person’s name, the basis of his/her entitlement (i.e., “legatee,” “surviving spouse,” etc.), and his/her

age, if under 21.
2.

Show any of the persons listed in Item 1 who are under a legal disability. In the space for “Legal Disability,” enter the
nature of the disability, such as the individual is an “incapacitated person.” If appointed by the court, show the legal
representative’s name and address. In the space for “Capacity,” enter the official title or description of the representative
acting, for example, “legal guardian” or “conservator.” The representative must submit a certified copy under court seal of
the letters of appointment dated within one year of submission.

PART D – DISPOSITION OF SECURITIES AND PAYMENTS TO PERSONS ENTITLED
Complete Items 1 through 5.
1. Enter the name of only one entitled person in each Part D, Item 1. (A separate Part D must be completed for each person
entitled and each type of distribution desired.) Enter the appropriate social security or employer identification number.

2. Describe only the securities or checks to which the person shown in Item 1 is entitled, in whole or in part:
TITLE OF SECURITY – Identify each security by series, interest rate, type, CUSIP, call and maturity date, as appropriate. If
describing a check, insert the word “check.”
ISSUE DATE – Provide the issue date of each security or check.
FACE AMOUNT – Provide the face amount (par or denomination) of each security or check.
IDENTIFYING NUMBER (if applicable) – Provide the serial number of each security, the confirmation number, or the check
number.
REGISTRATION – Provide the registration of each security, check, or account; also provide the account number, if any.

Part D continued on next page.

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PD F 5394

PART D – DISPOSITION OF SECURITIES AND PAYMENTS TO PERSONS ENTITLED (continued from previous page)
EXAMPLES:
TITLE OF SECURITY

ISSUE
DATE

FACE AMOUNT

Paper Marketable Security

9 1/8 % TREASURY BOND OF
2004-2009 MATURES 5/15/09
CUSIP 912810CG1
Electronic Marketable Security

CUSIP 912795QW4
Electronic Series I Savings Bond

SERIES I
Paper Series EE Savings Bond

SERIES EE
Check

CHECK

IDENTIFYING NUMBER
Serial #

5/15/79

$5,000

2/5/04

$1,000

1/1/02

$100

7/99

$100

7/26/04

$351.02

123

Confirmation #

12345
Serial #

C-123,456,789-EE
Check #

502123456

REGISTRATION
JOHN DOE AND BOB DOE
SSN 222-22-2222
ACCT # 4800-123-1234
JIM DOE
SSN 222-22-2222
ACCT # N-111-11-1111
BOB SMITH
SSN 222-22-2222
BILL SMITH
OR JANE SMITH
JIM SMITH

If unsure what to provide in each of the areas, furnish all information shown on the face of the security or check in the space for REGISTRATION.

3.

4.

5.
6.

Mark the block “In full” if the person listed in Item 1 is to receive the entire value of the securities and/or checks described in
Item 2; or if the person listed in Item 1 is not to receive the entire value, mark the second block and provide the amount,
fractional share, or percentage to which he/she is entitled.
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). 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.
• Requests for reissue or transfer (when applicable) may not be available if there is not sufficient time to process the
transaction before the security matures. If we are unable to process the reissue or transfer request before the security
matures, payment will be issued. All Saving Bonds of Series A, B, C, D, F, G, J, and K, and Savings Notes have reached
final maturity and must be redeemed.
• Any interest which is 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.
Provide mailing instructions. (If payment by Direct Deposit is desired, complete Item 6 instead.)
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/her representative, who can authorize such a deposit, must also sign in Part E. For marketable Treasury Bills, Notes,
Bonds, and TIPS held in book-entry, payment may be made by Direct Deposit only if one individual is entitled to payment.

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 officer. The signatures to the form must be signed in the officer’s presence. The certifying officer must
affix the seal or stamp which is used when certifying requests for payment. Authorized certifying officers are available at most
banking institutions, including credit unions.
ADDITIONAL EVIDENCE – The Commissioner of the Public Debt, as designee of the Secretary of the Treasury, reserves the
right in any particular case to require the submission of additional evidence.
RETURN OF EVIDENCE – If you want the evidence submitted with this form returned to you, please provide a written request
when you submit the form and evidence.
WHERE TO SEND – Send the completed form, all of the securities, if any, and required evidence to the appropriate address as
shown at the beginning of this form.
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 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 Public Debt, Forms
Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form to the above address; send to address shown in "WHERE TO
SEND" above.

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PD F 5394