Form PD F 1832 PD F 1832 Special Form of Assignment for U.S. Registered Definitiv

RESET
For official use only:
Customer Name

Customer No.

PD F 1832 E
Department of the Treasury
Bureau of the Public Debt
(Revised January 2007)

OMB No. 1535-0059

SPECIAL FORM OF ASSIGNMENT FOR
U.S. REGISTERED DEFINITIVE SECURITIES

WARNING: Use only for securities in certificate form (NOT book-entry). This form by itself has no monetary value and is NOT evidence of ownership of
these securities. This form will not support a transaction unless accompanied by the securities (except for securities previously tendered).

1.

Identification of Securities

CUSIP
(Title of Securities)

TITLE OF SECURITY
(Identify by interest rate, title, call
and maturity dates)

2.

SERIAL NUMBER

REGISTRATION
(Exact inscription on each security)

FACE AMOUNT

For value received, I assign to the Secretary of the Treasury for: (Select only one)
a.

-

Conversion to book-entry and deposit in Legacy Treasury Direct® account number

-

registered
b.

Conversion to book-entry and deposit with
(Name of Commercial Financial Institution)

ABA Routing Number
Account/Instructions

c.

Payment of matured/called securities to another party:
(Name of Payee)

d.
3.

Other:

I am the owner or the authorized representative of the owner of the securities described on this form. I authorize discharge of the
registrations on the books of the Department of the Treasury.
Are additional securities described on an attached sheet?

Yes

No

(You must check one box.)

You must wait until you are in the presence of a certifying officer to sign this form.

Sign Here:
(Signature by or on behalf of owner)

(Additional signature
if required)
(

Certifying Officer – The individual must sign in your presence. Complete the certification and affix your stamp or seal.
I CERTIFY that

whose identity (or the identity of each of whom) is known or was
(Name/Names)

proven to me, personally appeared before me the

,

day of
(Month)

,

at
(City)

and signed this assignment.

(State)

(OFFICIAL STAMP
OR SEAL)

(Signature and title of certifying officer)

(Address)

A notary public may not certify this request.

,
(Year)

INSTRUCTIONS
USE OF FORM
Use PD F 1832 to certify assignments of U. S. registered definitive securities. It is appropriately used only at the discretion of
the Bureau of the Public Debt in one of the following circumstances:
To correct a defective assignment already made on the back of a registered definitive security;
To accommodate owners required to sign a large number of registered definitive securities; or
To obtain the assignment of two or more geographically separated assignors.
COMPLETION OF FORM – Print clearly in ink or type all information requested.
ITEM 1.

IDENTIFICATION OF SECURITIES
Furnish the title of the securities and all identifying information shown on the face of the securities. The title of the
securities includes the interest rate, type of security (note, bond, etc.), letter series if a note, call year if applicable,
and maturity year. Show the CUSIP and furnish the face amount, serial number, and inscription of each security.
If additional space is needed to identify other securities with the same inscription, attach another sheet and indicate
this by marking the appropriate box in Item 3.

ITEM 2.

ACTION REQUESTED
Investors may use PD F 1832 for the transactions listed in Items 2a through 2d. Check the appropriate box for the
transaction desired. Only one transaction may be requested; a separate request must be completed for each
transaction.
a. Convert the definitive (paper) registered securities to an account in Legacy Treasury Direct®. Furnish the
Legacy Treasury Direct account number and registration. There is no charge for conversion. To obtain a
Legacy Treasury Direct account number, complete and submit a New Account Request, PD F 5182.
b. Convert the definitive (paper) registered securities to a book-entry account with a commercial financial
institution. Furnish the name of the institution, the ABA Routing Number which identifies the institution,
account information, and any special instructions for delivery.
c. Allow matured or called definitive (paper) registered securities to be paid to another party. The payee must
execute IRS Form W-9 and submit it with the securities.
d. Request any other authorized transaction.
information.

ITEM 3.

Provide the type of transaction and any other appropriate

AUTHORIZATION AND CERTIFICATION
You must sign the form in the presence of an authorized certifying individual. You must also check the appropriate
box to show whether additional securities are described on an attached sheet. If another sheet is attached for
identification of other securities, you must initial and date that sheet.
The certifying individual must complete the certification section. Authorized certifying officers are available at
financial institutions, including credit unions, in the United States. A notary public is not an acceptable certifying
officer. Additional forms may be used, if necessary, to accommodate more than two owners. If joint owners of a
security are in different locations, each person may complete a separate PD F 1832 in the presence of an
authorized certifying individual.

ADDITIONAL INFORMATION – For a complete list of authorized certifying officers, a copy of the regulations, additional forms,
or other information, contact the office shown in "Where to Send" below. If you prefer, call us at (304) 480-7711.
WHERE TO SEND – Send the completed form, and any additional information or evidence, to the Department of the Treasury,
Bureau of the Public Debt, PO Box 426, Parkersburg, WV 26106-0426.
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 15 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 "WHERE TO SEND" above.