Form 5178 Transaction request

PD F 5178 E
Department of the Treasury
Bureau of the Public Debt
(Revised October 2003)

OMB No. 1535-0069

TRANSACTION REQUEST

TreasuryDirect

Call us at 1-800-722-2678

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
This form will not be accepted if it has any alterations or corrections.
Pages 1 and 2 must be on a single sheet of paper, front to back. Therefore, if you are printing the form from the Internet, print it double-sided
or photocopy page 2 onto the back of page 1 before you sign the form. Transactions received with separate pages 1 and 2 will be rejected.

1. TreasuryDirect ACCOUNT INFORMATION
TreasuryDirect ACCOUNT NUMBER:
ACCOUNT NAME:

2. TRANSACTIONS REQUESTED

Mark the box next to each transaction requested and show the information as it should
appear on your TreasuryDirect account.

CONSOLIDATION OF TreasuryDirect ACCOUNTS - For identical accounts only. Provide the number(s) of the
account(s) from which securities are to be moved and the number of the account into which they are to be deposited.
TreasuryDirect Account No(s) to be closed:

⇒
(Surviving TreasuryDirect Account No.)

NAME CHANGE - Provide the complete account name as it should appear. This type of change usually requires a
certified signature; see items 2 and 3 in the instructions.

ADDRESS CHANGE - Provide the complete address as it should appear. You can also use our web services at
www.treasurydirect.gov to change your account address.

TELEPHONE NUMBER CHANGE - Provide each complete number, including extension, if applicable. You can also use
our web services at www.treasurydirect.gov to change your telephone number.
(Daytime Telephone Number)

(Alternate Telephone Number)

PAYMENT INFORMATION CHANGE - Provide the complete direct deposit or debit information as it should appear.
This type of change requires a certified signature; see items 2 and 3 in the instructions.
Name(s) on the Account:
Checking

Type:

Account No.:

Savings
(Financial Institution's Name)

Routing No.

(Financial Institution's Telephone No.)

TAXPAYER IDENTIFICATION NUMBER CORRECTION - Use only for a correction. Provide the correct number.
OR
(First-Named Owner's Social Security Number)

(Owner's Employer Identification Number)

RESET

3. SIGNATURES AND CERTIFICATION
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 provisions of the Department of the Treasury Circular, PD Series No. 2-86 (31 CFR
Part 357) and 1-93 (31 CFR Part 356).
For taxpayer identification number corrections, I certify under penalty of perjury that:
1. The taxpayer identification number shown is my correct taxpayer identification number (or I am waiting for a number to be issued
to me), and
2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the
Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or
(c) I have been notified by the Internal Revenue Service that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien).
(Instructions - You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return.)
The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup
withholding.
If a certified signature is required, you must wait until you are in the presence of a certifying officer to sign this form.
If there are two owners joined by the word "and," both may have to sign (see the instructions).

Sign Here: ⇒
(Signature)

(Title, if appropriate)

Address:
(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

Date:
(Daytime Telephone No.)

Sign Here: ⇒
(Signature)

(Title, if appropriate)

Address:
(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

Date:
(Daytime Telephone No.)

Certifying Officer

The individuals must sign in your presence and you must complete the certification and affix your stamp or seal.
Brokers must use a Medallion Stamp (original signature is required).
Certification by a notary public is NOT acceptable.
Certification cannot be detached from the request.

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)

(Name of Financial Institution and Telephone/Fax Numbers)
(Notary Certification is NOT Acceptable)
(Number and Street or Rural Route)

(City)

I CERTIFY that

(State)

(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)

(Name of Financial Institution and Telephone/Fax Numbers)
(Notary Certification is NOT Acceptable)
(Number and Street or Rural Route)

(2)

(City)

(State)

(ZIP Code)

PD F 5178

INSTRUCTIONS
PURPOSE OF FORM – Use this form to request consolidation of two or more TreasuryDirect accounts into a single TreasuryDirect
account, or to request changes or corrections to any of the following information for your TreasuryDirect account:
•

name

•

telephone number(s)

•

address

•

payment information

•

taxpayer identification number
(correction only)

IMPORTANT NOTICES
This form can't be used to transfer securities.
Only original signatures will be accepted (stamped signatures are not acceptable).
If you are a corporation with a governing body, a resolution or a PD F 5189 must accompany this form.
If any person signing this form is acting in a fiduciary capacity, failure to provide legal evidence may delay processing.
This form must be signed in all cases. Certification of the signature is required if you add or delete a beneficiary or second
owner, if you change the payment information, if you change your name (other than a minor change) and don't submit
supporting evidence, if you change your registration from an individual account to your grantor trust, or if you change your
registration from a grantor trust to an individual account.
This form will not be accepted with alterations or corrections.
Pages 1 and 2 must be on a single sheet of paper, front to back. Therefore, if you are printing the form from the
Internet, print it double-sided or photocopy page 2 onto the back of page 1 before you sign the form. Transactions
received with separate pages 1 and 2 will be rejected.
COMPLETION OF FORM – Print clearly in ink or type all information requested.
ITEM 1.

TreasuryDirect ACCOUNT INFORMATION

Provide your TreasuryDirect Account Number. Your TreasuryDirect Account Number is shown on your Statement of Account,
immediately above the Account Holdings section. Provide the name(s) under which the account is registered; this is shown in the
address block of your Statement of Account.
ITEM 2.

TRANSACTIONS REQUESTED

Mark all of the boxes that apply and provide the information requested.
CONSOLIDATION OF TreasuryDirect ACCOUNTS – Mark this box to consolidate two or more of your TreasuryDirect
accounts. All TreasuryDirect accounts to be consolidated must be identical; the accounts must have the same name, address,
taxpayer identification number, and payment information. Provide the number(s) of the account(s) from which securities are to
be moved in the spaces provided under "TreasuryDirect Account No(s) to be closed:", and provide the number of the account
into which the securities are to be deposited on the line above "Surviving TreasuryDirect Account No."
NAME CHANGE – Mark this box to change the name that currently appears on your account. Provide the complete account
name as it should appear.
•

You may NOT use this form to remove the first-named owner from your account.

•

You may use this form to add or remove the name of a second owner or beneficiary; a certified signature is
required for this type of change.

•

You may use this form to change your registration to or from a trust IF the taxpayer identification number
is NOT changing. If you want to change your registration to a trust and a different taxpayer identification number
will be used, open a new account with a New Account Request (PD F 5182) and then transfer the securities to the
new account with a Security Transfer Request (PD F 5179).

•

Minor name corrections, such as misspellings, adding or deleting a middle name or initial, or substituting a
common nickname require your signature, but the signature doesn’t have to be certified.

•

Name changes due to marriage must be signed "(current name) changed by marriage from (former name)" and,
unless you submit a copy of your marriage certificate, your signature must be certified. For name changes not due
to marriage, you must submit a certified copy of the legal document showing the name change. If supporting
evidence is submitted, your signature to the form does not have to be certified.

ADDRESS CHANGE – Mark this box to change the address that currently appears on your account. Provide the complete
address as it should appear.
TELEPHONE NUMBER CHANGE – Mark this box to change the telephone number or numbers that currently appear on your
account. Provide the correct number or numbers, including area codes and, if appropriate, your extension.
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PD F 5178

PAYMENT INFORMATION CHANGE – Mark this box to change the direct deposit or debit information that currently appears
on your account. If both the TreasuryDirect account and the receiving financial institution account are in the names of
individuals, then at least one of the individuals named on the TreasuryDirect account must be named on the deposit account.
NOTE: Check with your financial institution to verify your account can accept debit transactions.
Provide the complete direct deposit or debit information as it should appear:
•
•
•
•
•
•

Name(s) on the Account – Show the name or names as it/they appear on the account at your financial institution.
Account No. – Show the account number at your financial institution.
Type – Mark the appropriate box to indicate whether the account is "checking" or "savings."
Routing No. – Show your financial institution's ABA identifying number. This is the routing/transit number which
identifies the institution. You may need to contact the financial institution to obtain this number.
Financial Institution's Name – Show the name of the financial institution.
Financial Institution's Telephone Number – Show the telephone number of the financial institution.

A certified signature is required for any payment information change.
TAXPAYER IDENTIFICATION NUMBER CORRECTION – Mark this box to correct the taxpayer identification number that
currently appears on your account. Provide the correct number for the first-named owner.
ITEM 3.

SIGNATURES AND CERTIFICATION

SIGNATURES – This form must be signed in all cases. The owner named on the TreasuryDirect account, his/her authorized
representative, or the person entitled to the account must sign the form in ink, date it, and provide his/her title (if applicable), home
address, and daytime telephone number. If there are two owners joined by the word "and," both must sign this form if it
involves a name change (other than a minor change), payment information change, or consolidation of accounts. If a
correction of the taxpayer identification number is requested, the form must be signed by the first-named owner whose
taxpayer identification number is shown.
Certification of the signature is required if you add or delete a beneficiary or second owner, if you change the payment information,
if you change your name (other than a minor change) and don't submit supporting evidence, if you change your registration from an
individual account to your grantor trust, or if you change your registration from a grantor trust to an individual account.
If the account is registered in the name of an organization or corporation, a current Resolution for Security Transactions
(PD F 5189) or a corporate resolution must be on file with your TreasuryDirect office. If not already on file, you must submit a
PD F 5189 or your own corporate resolution with this request.
CERTIFICATION – If certification is applicable, each person whose certified signature is required must appear before and establish
identification to the satisfaction of an authorized certifying officer and sign the form in the officer’s presence. The certifying officer
must fully complete the certification blocks provided and affix the seal or stamp which is used when certifying requests for payment.
Brokers must use a Medallion Stamp (original signature is required).
Authorized certifying officers include authorized employees of insured depository institutions and corporate central credit unions.
For a complete list of such officers see Department of the Treasury Circular No. 300, 31CFR Part 315.
Please note that certification by a notary public is NOT acceptable and that certification cannot be detached from the
request.
Pages 1 and 2 of this form must be on a single sheet of paper, front and back. Therefore, if you are printing the form from
the Internet, print it double-sided or photocopy page 2 onto the back of page 1 before you sign the form. Transactions
received with separate pages 1 and 2 will be rejected.
WHERE TO SEND – Send the completed form to your TreasuryDirect office. You can find the TreasuryDirect address on your
Statement of Account or on the web (www.treasurydirect.gov). To ensure timely processing, this form must be received at least ten
business days in advance of:
• the maturity date of the security, and
• an interest payment date for the security.
CONTACT – Call us toll-free in the United States at 1-800-722-2678. Outside the U.S.? Call us at (617) 994-5500.
CONFIRMATION OF TRANSACTION(S) – You will receive a TreasuryDirect Confirmation of Change in Investor Account Information
after your transaction has been processed. A Statement of Account will be sent for each account when TreasuryDirect accounts are
consolidated.
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 10 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 correct address shown in "WHERE TO SEND" above.

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PD F 5178