5188 Power of Attorney for Security Transactions

RESET
OMB No. 1535-0069

PD F 5188 E
Department of the Treasury
Bureau of the Public Debt
(Revised June 2001)
www.treasurydirect.gov
1-800-722-2678

POWER OF ATTORNEY
FOR SECURITY TRANSACTIONS
SEE INSTRUCTIONS - TYPE OR PRINT IN INK ONLY - NO ALTERATIONS OR CORRECTIONS
FOR DEPARTMENT USE

1. TreasuryDirect ACCOUNT INFORMATION
TreasuryDirect ACCOUNT NUMBER

DOCUMENT AUTHORITY

ACCOUNT NAME
APPROVED BY

This Power of Attorney is in effect for ALL securities maintained in this account during the term of
authorization.

DATE APPROVED

2. POWER OF ATTORNEY
Hereby Appoints

Name of Grantor

Name of Grantee

Attorney-in-fact, individually or in a fiduciary capacity, with authority to perform any transactions to the account described above
[including, but not limited to, change of payment information; transfer or sale of securities; purchase by ACH debit (Pay Direct ®); or
reinvestments].
How long is the term of this authorization?
Until revoked. This Power of Attorney shall not be affected by the Grantor’s subsequent incapacity or disability.
For the attached transaction(s) only.
(Unless otherwise indicated, the term of this authorization will be for the attached transaction(s) only.)

3. AUTHORIZATION

YOU MUST WAIT UNTIL YOU ARE IN THE PRESENCE OF A CERTIFYING INDIVIDUAL TO SIGN THIS FORM.

The undersigned hereby ratifies any and all authorized transactions by the designated attorney-in-fact.

Signature
(Signature)

4. CERTIFICATION

Telephone

Date

The Grantor’s signature MUST be certified by an authorized certifying individual.

Instructions to Certifying Individual: Name of person(s) who appeared and date of appearance MUST be completed.

I certify that

, whose identity(ies) is/are known or proven
Name of Person(s) Who Appeared

to me, personally appeared before me this

ACCEPTABLE CERTIFICATIONS:
1. Financial Institution’s official seal or stamp
(Such as Corporate Seal or Signature
Guaranteed Stamp).
2. Notary Public’s official seal or stamp.

day of

Month/Year

and signed this Power of Attorney.

Signature and Title of Certifying Individual

Name of Financial Institution

Address

City/State/ZIP Code

MY COMMISSION EXPIRES

(For notaries only)

Telephone

(OVER)

RESET
PD F 5188
Department of the Treasury
Bureau of the Public Debt
(Revised June 2001)
www.treasurydirect.gov
1-800-722-2678

INSTRUCTIONS FOR COMPLETING A
POWER OF ATTORNEY FOR
SECURITY TRANSACTIONS

PURPOSE
You can use this form to appoint and authorize an attorney-in-fact to conduct transactions regarding TreasuryDirect securities.
IMPORTANT NOTE
• This form gives the individual or organization you name as attorney-in-fact broad powers to handle your
TreasuryDirect securities. If you have questions about these powers, you should seek competent legal advice before
signing this form.
• Only original signatures and forms will be accepted (stamped signatures are not acceptable).
• Unless all the required information is provided legibly, there may be a delay in processing this form. To avoid delays, read the
instructions carefully and type or print clearly in ink only. Where spaces are provided, enter only one number in each space.
• POWERS OF ATTORNEY WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS.
1. TreasuryDirect ACCOUNT INFORMATION
Provide your TreasuryDirect ACCOUNT NUMBER and ACCOUNT NAME. You will find this information on your TreasuryDirect
Statement of Account. All securities maintained now and hereafter in this account are subject to this power of attorney.
2. POWER OF ATTORNEY
Provide the name of the GRANTOR (the individual or organization granting the power of attorney) and the GRANTEE
(the individual or organization being appointed attorney-in-fact). Completion of this form will permit the named individual or
organization to conduct any authorized transactions regarding the account listed on the front of the form. (The GRANTEE is not
authorized to transfer securities to an account in his/her own name.)
3. AUTHORIZATION
The grantor must sign and date the request form in ink. If the grantor is an organization, a resolution authorizing the appointment
of an attorney-in-fact must be attached. Resolution for Security Transactions (PD F 5189) may be used for this purpose.
Is the grantor a trustee?

yes

no

If yes, you must provide excerpts of the trust including: the page showing name and date of trust; the page showing an agent or
attorney-in-fact may be appointed; the signature page, and the authentication statement.
4. CERTIFICATION
Certification of the grantor’s signature is required. Acceptable certifying individuals include authorized employees of insured
depository institutions and corporate central credit unions. A notary public may also certify this form.
SUBMISSION
Completed forms should be submitted to Marketable Assistance Branch, Bureau of the Public Debt, P.O. Box 426,
Parkersburg, WV 26106-0426.
Retention of Power of Attorney - If this form is submitted in support of a specific transaction request, subsequent requests should
be accompanied by additional power of attorney forms. If this Power of Attorney is to remain in effect until revoked, this form will be
retained at the Bureau of the Public Debt. In order to be effective, changes or revocations to this Power of Attorney must be in
writing (notarized or certified) and must be sent to the Bureau of the Public Debt. The Department of the Treasury (Bureau of the
Public Debt) will not be responsible for recognizing changes or revocations not submitted.
CONTACT
Call us toll-free in the United States at 1-800-722-2678. Outside the U.S.? Call us at (617) 994-5500.
NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
The collection of the information you are requested to provide on this form is authorized by 31 U.S.C. Ch. 31 relating to the public debt of the United States. The furnishing of a
social security number, if requested, is also required by Section 6109 of the Internal Revenue Code (26 U.S.C. 6109).
The purpose for requesting the information is to enable the Bureau of the Public Debt and its agents to issue securities, process transactions, make payments, identify owners and
their accounts, and provide reports to the Internal Revenue Service. Furnishing the information is voluntary; however, without the information Public Debt may be unable to process
transactions.
Information concerning securities holdings and transactions is considered confidential under Treasury regulations (31 CFR, Part 323) and the Privacy Act. This information may be
disclosed to a law enforcement agency for investigation purposes; courts and counsel for litigation purposes; others entitled to distribution or payment; agents and contractors to
administer the public debt; agencies or entities for debt collection or to obtain current addresses for payment; agencies through approved computer matches; Congressional offices
in response to an inquiry by the individual to whom the record pertains; as otherwise authorized by law or regulation.
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 the correct address shown in the instructions.

and Pay Direct are registered trademarks of the Bureau of the Public Debt.