5191 Application for recognition as natural guardian of a min

PD F 5191 E
Department of the Treasury
Bureau of the Public Debt
(Revised June 2001)

OMB No. 1535-0069

APPLICATION FOR RECOGNITION AS
NATURAL GUARDIAN OF A MINOR

www.treasurydirect.gov
1-800-722-2678

SEE INSTRUCTIONS - TYPE OR PRINT IN INK ONLY - NO ALTERATIONS OR CORRECTIONS

1. TreasuryDirect ACCOUNT INFORMATION

FOR DEPARTMENT USE

ACCOUNT NUMBER(S):
DOCUMENT AUTHORITY

APPROVED BY

DATE APPROVED

2. MINOR
NAME:
TAXPAYER IDENTIFICATION NUMBER:
DATE OF BIRTH:

3. GUARDIAN
NAME:
ADDRESS:
TELEPHONE:
RELATIONSHIP TO MINOR:

PARENT

FURNISH CHIEF SUPPORT

OTHER (specify)

MARRIED? If your spouse did not apply as natural guardian with you, please have your spouse sign after the following statement:
I consent to the above named parent acting as the guardian for our minor child.

Signature

SEPARATED OR DIVORCED? You must furnish a certified copy of court records showing you have custody of the minor.
NAMES AND ADDRESSES OF OTHERS WHO REGULARLY CONTRIBUTE TO THE MINOR’S SUPPORT, AND THE
PERCENTAGE OF THEIR CONTRIBUTIONS:

DOES THE MINOR RESIDE WITH YOU?

YES

NO

IF NO, PROVIDE THE NAME AND ADDRESS OF THE PERSON WITH WHOM THE MINOR RESIDES:

SEE INSTRUCTIONS FOR PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE

(OVER)

RESET

4. AUTHORIZATION

You must wait until you are in the presence of a certifying individual to sign this form.
(If there are two owners joined by the word “and,” both must sign.)

I REQUEST THAT I BE RECOGNIZED AS NATURAL GUARDIAN OF THE SAID MINOR FOR PURPOSES OF FURNISHING
THE PAYMENT INSTRUCTIONS FOR THE ACCOUNTS LISTED AND TO EXECUTE ANY NECESSARY TRANSACTION
REQUESTS FOR THOSE ACCOUNTS.

I CERTIFY THAT NO LEGAL GUARDIAN OR SIMILAR REPRESENTATIVE HAS BEEN APPOINTED FOR THE SAID MINOR
AND NO SUCH APPLICATION IS CONTEMPLATED AND THAT THE SAID MINOR HAS AN INTEREST IN WHOLE OR IN PART
IN SECURITIES HELD IN THE ACCOUNTS LISTED.

IN CONSIDERATION FOR MY RECOGNITION AS NATURAL GUARDIAN OF THE MINOR, I HEREBY AGREE THAT I WILL
PROMPTLY NOTIFY THE BUREAU OF THE PUBLIC DEBT IF (A) THE MINOR’S DISABILITY IS REMOVED UNDER THE
LAWS OF THE STATE OF HIS OR HER RESIDENCE, (B) A LEGAL GUARDIAN OR SIMILAR REPRESENTATIVE IS APPOINTED FOR THE MINOR’S ESTATE, (C) I NO LONGER FURNISH CHIEF SUPPORT FOR THE MINOR (WHEN SUPPORT IS THE
BASIS FOR RECOGNITION), OR (D) THE MINOR DIES.

SIGNATURE(S)

DATE

5. CERTIFICATION The natural guardian’s signature MUST be certified by an authorized certifying individual.

Instructions to Certifying Individual:
1. Name of person(s) who appeared and date of appearance MUST be completed.
2. Certification CANNOT be detached from this application.

I CERTIFY THAT

, WHOSE IDENTITY(IES) IS/ARE

NAME(S) OF PERSON(S) WHO APPEARED

KNOWN OR PROVEN TO ME, PERSONALLY APPEARED BEFORE ME THIS

DAY OF
MONTH/YEAR

AT

AND SIGNED THIS APPLICATION.
CITY/STATE

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.

SIGNATURE AND TITLE OF CERTIFYING INDIVIDUAL

NAME OF FINANCIAL INSTITUTION

ADDRESS

CITY/STATE/ZIP CODE

TELEPHONE
MY COMMISSION EXPIRES:
(FOR NOTARIES ONLY)

CERTIFICATION BY A NOTARY PUBLIC IS ACCEPTABLE.

PD F 5191 E
Department of the Treasury
Bureau of the Public Debt
(Revised June 2001)

INSTRUCTIONS FOR COMPLETING AN
APPLICATION FOR RECOGNITION AS
NATURAL GUARDIAN OF A MINOR

www.treasurydirect.gov
1-800-722-2678

PURPOSE
This form can be used to:
• apply for recognition as a natural guardian of a minor who owns, wholly or in part, TreasuryDirect securities in an estate
where a legal representative has not been appointed.
• apply for recognition as a natural guardian when a designated natural guardian is no longer acting. (A death certificate,
physician’s certificate, or certified evidence of court action must be submitted as proof of the designated natural guardian’s
inability to act.)
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.
• This form MUST be signed in all cases.
• APPLICATIONS WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS.
WHO MAY APPLY
The parent with whom the minor resides may apply. If the minor resides with both parents, either or both may apply. The
parent who has not joined in the application should consent by signing the statement within the box
in Section 3. If the parents are separated or divorced, no consent is required provided that a certified copy of court records is
furnished showing that the parent applying has custody. If the minor does not reside with either parent, the person who
furnishes the minor’s chief support may apply.
No application will be considered if the Department of the Treasury is on notice that 1) the minor’s disability no longer exists
under the laws of the state of his or her residence, 2) a legal guardian or similar representative of the minor’s estate had been
appointed, 3) the applicant is not entitled to act as natural guardian, or 4) the minor has died.
1. TreasuryDirect ACCOUNT INFORMATION
Provide the ACCOUNT NUMBER(S) of all TreasuryDirect accounts owned wholly or in part by the minor.
2. MINOR
Provide the minor’s NAME, TAXPAYER IDENTIFICATION NUMBER, and DATE OF BIRTH.
3. GUARDIAN
Provide your NAME and ADDRESS, and indicate your relationship to the minor. Remember: If you are married and your spouse
did not apply as natural guardian with you, please have your spouse sign the statement within the box. If you’re separated
or divorced, furnish a certified copy of court records showing you have custody of the minor.
If you are applying as the furnisher of chief support for the minor, provide the names and addresses of others who regularly
contribute to the minor’s support and the extent of their contributions (expressed as a percentage of the minor's total support).
Indicate whether the minor resides with you. If not, provide the name and addresses of the person with whom the minor resides.

4. AUTHORIZATION
Read the authorization statement carefully. In the presence of an authorized certifying individual, sign and date the form in ink.
5. CERTIFICATION
Certification of your signature is required. Acceptable certifying individuals include authorized employees of insured depository
institutions and corporate central credit unions. Certification date, address, and telephone number of the financial institution
is required. A notary public may also certify this form.

SUBMISSION
Completed forms should be submitted to your TreasuryDirect office. You can find the TreasuryDirect address on your Statement
of Account or on the web (www.treasurydirect.gov). This form should be submitted in support of a specific transaction request.
Subsequent requests should be accompanied by additional natural guardian application forms.
Contact
Call us toll-free in the United States at 1-800-722-2678. Outside the U.S.? Call us at (617) 994-5500.

TreasuryDirect Electronic Services
Enjoy the convenience of our TreasuryDirect electronic services from the comfort of your home using your
computer (www.treasurydirect.gov) or a touch-tone phone (1-800-722-2678).
Great hours! 8-8 ET, Monday through Friday, except for Federal holidays (24 hours a day for Reinvest Direct ®!)
Here’s what you can do:
• Buy a security
• Reinvest maturing securities
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• Get your overall account par balance (Web users get even more details!)
• Change your address and phone number, too! (Web users only)

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; instead, submit completed form in the manner described previously under SUBMISSION.

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