Form 2362 Authorization for Purchase and Request for Change U.S. S

SB-2362 E
(OMB Approval 1535-0111)

RESET

AUTHORIZATION FOR PURCHASE AND REQUEST FOR CHANGE
UNITED STATES SERIES EE SAVINGS BONDS OR
UNITED STATES SERIES I (INFLATION-INDEXED) SAVINGS BONDS

PRINT IN INK OR TYPE
SOCIAL SECURITY or
EMPLOYEE PAYROLL NUMBER

DATE
EMPLOYEE'S NAME
(First Name)

DEPARTMENT/AGENCY

BUREAU OR OFFICE

LOCATION

A New
Allotment

REQUESTED ACTION
For allotment options, see your
campaign volunteer or payroll office.

(Last Name)

(Middle Name or Initial)

B Increase
Allotment

WORK PHONE

C Change
Denomination

D Change
Inscription

E Other Action

(Describe below)

OTHER ACTION
If checked above

If you checked A, B, or C above indicate amount to be allotted each pay period.
CHOOSE SERIES

EE

I BOND

SELECT DENOMINATION

$50

$

(The price of an EE bond is equal to half the denomination of the bond being purchased.)
(The price of an I bond is equal to the denomination of the bond being purchased.)

$75

$100

I Bond only

$200

$500

$1,000

I Bond or Series EE

BOND INSCRIPTION Complete the following if (a) you checked A or D above; or (b) you have multiple Bond allotments
OWNER'S NAME
(First Name)

(Middle Name or Initial)

(Last Name)

SOCIAL SECURITY NO. (Required)

ADDRESS

{

(Number and Street)
(City or Town)

(State)

Check one if you wish to designate a co-owner or beneficiary

CO-OWNER

(ZIP Code)

BENEFICIARY

NAME
(First Name)

(Middle Name or Initial)

(Last Name)

SOCIAL SECURITY NO. (Optional)
NOTE: Married women should use their given names, e.g., “Mary L. Smith”. If coowner or beneficiary is designated, the inclusion of that individual’s
Social Security number is desireable but not required. The use of courtesy titles is optional.

EFFECTIVE FIRST PAYROLL PERIOD AFTER
EMPLOYEE’S SIGNATURE
(Return signed form to your payroll office or campaign volunteer)
I hereby authorize the foregoing allotment from my pay for the purchase of U.S. Savings Bonds to be issued with the inscription shown on this form.
This Authorization is to remain in effect until cancelled by me in writing or termination of my employment.
NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
The Treasury Department’s Bureau of the Public Debt keeps records about who owns savings bonds. Please fill in the information that applies to you
so that we can issue savings bonds and keep accurate records as authorized by Title 31 of the United States Code, Chapter 31. We don’t disclose any
information except as authorized by law.
We estimate it will take you about 01 minute 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.