5189 Resolution for Security transactions

RESET
OMB No. 1535-0069

PD F 5189
Department of the Treasury

Bureau of the Public Debt

(Revised June 2001)

RESOLUTION FOR SECURITY
TRANSACTIONS

www.treasurydirect.gov

1-800-722-2678

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 resolution is in effect for ALL securities maintained in this account during the term of authorization.
2. RESOLUTION

(Provide the names and titles of individuals being granted authority. If more than one individual is named and all
must sign, use “and” between the names. If any one of the individuals may sign, use “or” between the names.)

DATE APPROVED

Resolved that:
EXPIRATION DATE

is/are authorized to perform any transactions for 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].
The authorized individual(s)
may
may not appoint an Attorney-in-fact with authority in turn to appoint one or more
substitutes. (“May not” will be assumed unless otherwise indicated.)
It is further resolved that any action taken by the individuals listed above is hereby ratified and that this authorization shall
1 year
2 years
other
from the date of cer tification. (One year will be assumed
remain in effect for
unless otherwise indicated.)

3. AUTHORIZATION

YOU MUST WAIT UNTIL YOU ARE IN THE PRESENCE OF A CERTIFYING INDIVIDUAL TO SIGN THIS
FORM. It must be signed by an officer other than the persons authorized herein to execute
transaction requests.

I certify that the foregoing is a true copy of a resolution adopted at a meeting of the governing body of:
Name of Organization

and that said meeting was duly called and held and that the resolution was duly adopted and is in full force.
SEAL OF THE
ORGANIZATION

4. CERTIFICATION

Signature(s)

Date

Title

Telephone

Certification required ONLY if Organization’s Seal is NOT affixed above.

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(s) 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 resolution.

Signature and Title of Certifying Individual

Name of Financial Institution

Address

City/State/ZIP Code

MY COMMISSION EXPIRES

Telephone

(For notaries only)

(OVER)

PD F 5189

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

INSTRUCTIONS FOR

COMPLETING A RESOLUTION
FOR SECURITY TRANSACTIONS

PURPOSE This form can be used to authorize individuals (by name and title) in an organization to conduct any transactions
regarding TreasuryDirect securities.
IMPORTANT NOTE
• 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. Spaces are provided for the account number; please enter only
one number in each space.
• RESOLUTIONS 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 resolution.
2. RESOLUTION
Provide the names and titles of the individuals being granted authority. If more than one individual is named, use the conjunction
“and” between the names if all the individuals must sign. If any one of the individuals may sign, use the conjunction “or” between
the names. Completion of this form will authorize the named individuals to conduct any transactions regarding the account
listed on the front of the form. REMINDER: The purchase price of securities bought using ACH debit (Pay Direct) will be
deducted from the account at the financial institution designated in TreasuryDirect.
Indicate whether the authorized individual has the authority to appoint an attorney-in-fact. If neither box is marked, it will be
assumed that the authority has not been granted.
3. AUTHORIZATION
An officer of the organization who is responsible for maintaining the organization’s records should sign and date the form. This
officer cannot be among those named on the front of the form (i.e., an officer may not sign his or her own authorization to
conduct transactions). The organization’s seal must be affixed to the form. If the organization does not have a seal, the form
must be certified.
4. CERTIFICATION
Certification of the officer’s signature is required only if the organization’s seal is not affixed to this form. 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 your TreasuryDirect office.
Retention of Resolution - If this resolution is submitted in support of a specific transaction request, subsequent requests
should be accompanied by additional resolution forms. If this resolution is to remain in effect for a longer period of time, this
form will be retained at the Bureau of the Public Debt. In order to be effective, changes or revocations to this resolution 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.