5179-1 Sell Direct Request

RESET
PD F 5179-1 E
Department of the Treasury
Bureau of the Public Debt
(Revised June 2003)

OMB No. 1535-0069

TreasuryDirect

SELL DIRECT® REQUEST

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 doublesided 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.
! Send the completed form to: FRB Chicago
Investment Division for Sell Direct
230 South LaSalle Street
Chicago, IL 60604

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

2. SECURITIES IDENTIFICATION AND AMOUNT (Check the box which applies and provide the information requested.)
Transfer and sell ALL my securities in the above TreasuryDirect Account.
Transfer and sell my securities totaling $

from the CUSIP's shown below:
(Increments of $1,000)

CUSIP

FRB Use
Reference Number

AMOUNT

.
(Additional forms are required for more than 10 CUSIP's.)

CUSIP

AMOUNT

$

$

$

$

$

$

$

$

$

$

Transfer and sell $

FRB Use
Reference Number

of my holdings from CUSIP Number:

.

(Increments of $1,000)

If you are NOT transferring all of your holdings for a CUSIP and it has sub-accounts, you must also list the specific
sub-account to be transferred. This information is shown on your TreasuryDirect Statement of Account.
SUB-ACCOUNT

AMOUNT
$

SUB-ACCOUNT

AMOUNT
$

SUB-ACCOUNT

AMOUNT
$

3. TRANSFER AND SALE AUTHORIZATION
I/We request the securities described above be transferred from my identified TreasuryDirect account to the Federal
Reserve Bank of Chicago (FRB Chicago). I/We also authorize FRB Chicago, as fiscal agent of the United States, to
sell the above identified securities and to charge a transaction fee for each security which will be deducted prior to
depositing the settlement amount due me/us. I/We understand FRB Chicago will make a reasonable effort to obtain a
price quote from at least three (3) government securities dealers and will sell the securities to the dealer with the
highest price quote for next day settlement. I/We agree to accept the price received by FRB Chicago from the dealer
selected as having the highest price quote. I/We understand the Treasury Department and FRB Chicago will not be
liable for changes in market conditions affecting the price received for the securities, or for any loss which I/we may
incur as a result of the transaction or the inability of FRB Chicago to complete the transaction.

4. 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).
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 must sign.

Sign Here: ⇒
(Signature)
(Signature)

(Title, if appropriate)

Address:
(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

(Daytime Telephone No.)

Sign Here: ⇒
(Signature)
(Signature)

(Title, if appropriate)

Address:
(Number and Street or Rural Route)

Certifying Officer

!
!
!
!

(City)

(State)

(ZIP Code)

(Daytime Telephone No.)

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 disposition request.

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)

(OFFICIAL STAMP
OR SEAL)

(Signature and Title of Certifying Officer)
(Name of Financial Institution and Telephone/Fax Numbers)

(Notary Certification is NOT Acceptable)

(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)

at

(Year)

, and signed this form.
(City)

(State)

(OFFICIAL STAMP
OR SEAL)

(Signature and Title of Certifying Officer)
(Name of Financial Institution and Telephone/Fax Numbers)

(Notary Certification is NOT Acceptable)

(Number and Street or Rural Route)

Par

Date Traded

1

(City)

(State)

FOR FRB CHICAGO USE ONLY
Issue
To

Time Traded

2

Price

Trader

3

(2)

(ZIP Code)

Settlement Date

4

5

PD F 5179-1

INSTRUCTIONS
PURPOSE OF FORM – Use this form to request the transfer of securities from a TreasuryDirect account to an account at
FRB Chicago, and the subsequent sale of the same securities.
IMPORTANT NOTICES
! The Treasury Department and FRB Chicago will not be liable for changes in market conditions affecting the price
received for the security, or for any loss which you may incur as a result of the transaction or the inability of FRB
Chicago to complete the transaction.
! 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 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.

SECURITIES IDENTIFICATION AND AMOUNT

Check the box that applies and provide the information requested. ALL REQUIRED INFORMATION IS LISTED ON
YOUR TreasuryDirect STATEMENT OF ACCOUNT.
# Check the first box to transfer and sell ALL of the securities in your TreasuryDirect account.
# Check the second box to transfer and sell one or more securities (but not all) of the securities in your
TreasuryDirect account. List the CUSIP number(s) and amount of the securities to be transferred (in $1,000
increments), as indicated below:
o CUSIP – The number (i.e., 912798XXX) that identifies the securities to be transferred (located under
the heading "SECURITY" on your Statement of Account).
o AMOUNT – The total dollar amount (at par) to be transferred.
# Check the third box to transfer and sell a portion of one security in your TreasuryDirect Account. Enter only
the amount being transferred (in $1,000 increments) and list the CUSIP number. To transfer and sell a
portion of a security listed in a sub-account, enter the sub-account number(s) and dollar amount(s) to be
transferred and sold. NOTE: The amount to be transferred and sold and the amount remaining in the
CUSIP must satisfy both the minimum and multiple holding requirements for the security.
If you list a Matured CUSIP Number that has been re-invested, or is within 10 days of reinvestment, FRB Chicago
will transfer and sell the current or the new CUSIP number and indicated dollar amount.
ITEM 3.

TRANSFER AND SALE AUTHORIZATION

Please carefully read this section before signing the form as it describes the nature of the transaction authorized.
You are transferring the identified securities to FRB Chicago for the sole purpose of having the securities sold. You
are authorizing the identified securities, once transferred, to be sold by FRB Chicago. A transaction fee will be
charged (see FEES for further information). Because FRB Chicago enters into an agreement to sell the securities on
the same day that it receives the securities, the authorization for the sale and transfer of the securities becomes
irrevocable when the transfer from your TreasuryDirect account to the account of FRB Chicago is made. FRB
Chicago will make a reasonable effort to obtain a price quote from at least three (3) government securities dealers
and will sell the securities to the dealer with the highest price quote for next day settlement. You agree to accept the
price received by FRB Chicago from the dealer selected as having the highest price quote. On the next full business
day after the trade date, the settlement amount will be released electronically by FRB Chicago to the account at the
financial institution currently designated to receive your TreasuryDirect payments. The Treasury Department and
FRB Chicago will not be liable for changes in market conditions affecting the price received for the securities or for
any loss which you may incur as a result of the transaction or the inability of FRB Chicago to complete the
transaction.
In the event FRB Chicago is unable to obtain at least one quote for the securities, the securities will be returned to
your TreasuryDirect account on the next full business day following the receipt of the securities by FRB Chicago, and
FRB Chicago will notify you. No transaction fee will be charged.
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PD F 5179-1

ITEM 4.

SIGNATURES AND CERTIFICATION

SIGNATURES – The owner named on the TreasuryDirect account, his/her authorized representative, or the person
entitled to the account must sign the form in ink, 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. The
signature(s) to this form must be certified.
CERTIFICATION – Each person whose 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 form(s) 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 disposition 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.
FEES – A transaction fee for the service will be charged for each security sold on your behalf. (A security is considered
as any amount within a TreasuryDirect account which is identified by a separate CUSIP number.) The FRB Chicago will
deduct the fee prior to depositing the settlement amount (also referred to as "net amount") to the account at the financial
institution currently designated to receive your TreasuryDirect payments. The amount of the fee is published by notice in
the Federal Register. Call TreasuryDirect for the current fee (see CONTACT below).
SETTLEMENT AMOUNT – The settlement amount (also referred to as "net amount") minus the transaction fee, will be
credited by direct deposit (electronic funds transfer) to the account at the financial institution currently designated to
receive your TreasuryDirect payments.
WHERE TO SEND – Send the completed form to:
FRB Chicago
Investment Division for Sell Direct
230 South LaSalle Street
Chicago, IL 60604
The form must be received at least ten (10) days in advance of:
• the maturity date of the security to ensure processing, and
• an interest payment date for the security to ensure processing prior to that date.
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 TRANSFER AND CONFIRMATION OF SALE – You will receive a TreasuryDirect Statement of
Account after your securities have been transferred, reflecting the change in the par amount being held in the identified
TreasuryDirect account.
You will receive a confirmation of the sale from FRB Chicago upon completion of the transaction, which will include such
information as the price, trade date, settlement date, settlement amount (also referred to as "net amount"), transaction
fee, and the yield to maturity. Trade date is the day the FRB Chicago enters into an agreement with a dealer for the sale
of the securities. Settlement date is the date the settlement amount is released to the account at the financial institution
currently designated to receive your TreasuryDirect payments. Price is the dollar amount paid for a security expressed as
a percent of its current par amount.
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 5179-1