5235 Report of nonreceipt, loss, theft, or destruction of fis

For official use only:
Customer Name

Customer No.

PD F 5235 E
Department of the Treasury
Bureau of the Public Debt
(Revised June 2002)

OMB No. 1535-0069

REPORT OF NONRECEIPT, LOSS, THEFT, OR DESTRUCTION OF
FISCAL AGENCY CHECK AND APPLICATION FOR REPLACEMENT

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

1.

RETURN THIS FORM TO:.
Bureau of the Public Debt, PO Box 1328, Parkersburg, WV 26106-1328.
Bureau of the Public Debt, PO Box 2186, Parkersburg, WV 26106-2186.
Bureau of the Public Debt, PO Box 426, Parkersburg, WV 26106-0426.
Federal Reserve Bank of

2.

REQUESTED ACTION:.
I/We hereby report the non-receipt, loss, theft, or destruction of a fiscal agency check issued in connection with United States
have requested
securities and request issuance of a replacement check. I/We
that a stop-payment order be placed against
hereby request
the check described in Item 4.

3.

SECURITY DESCRIPTION. The check was issued in connection with:
a. U.S. Savings or Retirement Bonds:
Series E
Series EE
Retirement Plan Bonds

Savings Notes
Series H
Individual Retirement Bonds

Series HH

Series I

b. U.S. Treasury Marketable Securities:
TreasuryDirect

Bill

Note

Bond

Inflation-Indexed

(Replacement payment may be by Direct Deposit.)

TreasuryDirect account number
Paper Securities:

Coupon Note
Other

Coupon Bond

(Term)

-

-

Registered Note

Registered Bond

c. Additional identifying information (loan title, pieces, face amount, form(s) of registration):

4.

CHECK DESCRIPTION. The check was issued in connection with:
a. Type of payment - The check was issued in connection with the following type of payment:
principal
Other

interest

discount or refund

coupons

b. Date of payment:
c. If the payment was made in connection with securities or coupon(s) presented for payment, indicate where presented:
Federal Reserve Bank of
Other
Bureau of the Public Debt, Parkersburg, WV
d. Social security number of first-named payee:
e. Amount of check:
f. Check serial number (if known):
g. Name(s) inscribed on the check:

h. The check was:
Never received

Received then lost

Received then stolen

i. If lost, stolen, or destroyed, was the check endorsed?

Yes

No

Received then destroyed

If Yes, show the exact form of endorsement.

j. Tell us the circumstances surrounding the loss, theft, or destruction:

k.

5.

I hereby warrant that all other payees named on the check(s) did not have access to the check and request waiver of the
requirement for all other payees to execute the application and agreement.

INDEMNIFICATION AGREEMENT AND SIGNATURE(S):

You must wait until you are in the presence of a certifying officer to sign this form.
In consideration of the issuance of a replacement check, I/We agree that if the missing check ever comes into my/our possession or
under my/our control, I/we will return it to the Bureau of the Public Debt or a Federal Reserve Bank. Further, I/we indemnify and hold
harmless the United States of America, the Department of the Treasury, and the payor Federal Reserve Bank, against all claims or
demands and all loss, damage, and expense, including legal fees and expenses, that may be incurred from paying the check reported
lost or refusing to pay the check if presented.

Sign here:

Sign here:
(Payee's Signature)

(Second Payee's Signature)

(Number and Street or Rural Route)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

(Daytime Telephone Number)

(E-Mail Address)

(E-Mail Address)

Certifying Officer – Each individual must sign in your presence.
Complete the certification and affix your stamp or seal. Brokers must use a Medallion Stamp.
I CERTIFY that

,

I CERTIFY that

whose identity is well-known or proved to me, personally
appeared before me this

day of

,

whose identity is well-known or proved to me, personally
,

appeared before me this

day of

(Month)

,

, at
(Year)

(City)

, at

(State)

(Year)

and signed this form.
(OFFICIAL STAMP
OR SEAL)

,
(Month)
,

(City)

(State)

and signed this form.
(Signature of certifying officer)

(OFFICIAL STAMP
OR SEAL)

(Title of certifying officer)

(Signature of certifying officer)

(Title of certifying officer)

(Address)

(Address)

For Notaries: My
Commission Expires

For Notaries: My
Commission Expires

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RESET

INSTRUCTIONS
USE OF FORM – Payee(s) can use this form to report the nonreceipt, loss, theft, or destruction of fiscal agency checks
and to apply for a replacement check. The form provides the necessary information to place a hold on the payment of the
missing check and constitutes an application for the issuance of a replacement check. Before a replacement check can
be issued, additional evidence and a bond of indemnity may be required.
COMPLETION OF FORM – Print clearly in ink or type all information requested. If more space is needed for any item,
use a plain sheet of paper and attach it to this form.
ITEM 1.

This Item is completed by the servicing office, advising you where to return the completed form.

ITEM 2.

Mark the appropriate box regarding stop-payment.

ITEM 3.

Mark the appropriate box(es) to show for what type(s) of securit(ies) the check was issued. Provide any
additional identifying information in Item 3c.

ITEM 4.

Furnish all requested information:

!
!
!
!
!
!
!
!
!
!

ITEM 5.

a.

Show the type of payment for which the check was issued.

b.

Furnish the date of payment.

c.

Indicate where the securities or coupons were presented for payment.

d.

Furnish the first-named payee's social security number.

e.

Show the amount of the check.

f.

Provide the serial number of the check.

g.

Provide the names that were inscribed on the check.

h.

Indicate whether the check was never received, or received and then lost, stolen, or destroyed.

i.

Indicate whether the check was endorsed and, if so, provide the exact form of endorsement.

j.

If the check was lost, stolen, or destroyed after receipt, furnish the circumstances of the loss, theft,
or destruction.

! k.

Mark this box if the other payees named on the check did not have access to the check and you
are requesting a waiver of the requirement for all payees to join in executing the application and
agreement.

Sign the form in ink and provide your complete home address, daytime telephone number, and e-mail
address, if applicable. If there are two payees, both must sign unless Item 4k. is marked. Each signature
must be certified (see CERTIFICATION below).

CERTIFICATION – You must appear before and establish identification to the satisfaction of an authorized certifying
officer, a notary public, or other officer authorized by law to administer oaths and sign the form in the presence of the
officer. The certifying officer must complete the certification forms provided and affix the seal or stamp which is used
when certifying requests for payment. Brokers must use a Medallion Stamp. A notary public or similar officer must also
show the expiration date of his/her commission. Authorized certifying officers are available at banking institutions,
including credit unions, in the United States. For a complete list of such officers see Department of the Treasury Circular
Nos. 300 and 530, current revisions, and Public Debt Series Nos. 3-80 and 2-98.
WHERE TO SEND – Send the completed form to the office shown in Item 1. If no box is checked in Item 1, send the form
to the servicing office which sent it to you.
NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
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 the
correct address shown in Item 1.

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