Form PD-F-1849 Disclaimer and Consent With Respect to United States Tre

RESET
For official use only:
Customer Name

Customer No.

PD F 1849 E
Department of the Treasury
Bureau of the Public Debt
(Revised April 2006)

OMB No. 1535-0113

DISCLAIMER AND CONSENT WITH RESPECT TO
UNITED STATES TREASURY SECURITIES

1. DESCRIPTION OF SECURITIES
TITLE OF SECURITY

ISSUE
DATE

FACE/PAR
AMOUNT

BOND NO. OR ACCOUNT NO.

REGISTRATION

(If more space is needed, use the continuation sheet on page 2.)

2. DISCLAIMER AND CONSENT
I disclaim all my right, title, and interest in and to the securities described on this form and consent to the payment,
refund of purchase price, transfer, reissue, or other disposition of them by:

(Name)

(Address)

My disclaimer and consent are given for the following reason(s):

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

Sign Here: ⇒
(Signature of Owner)

(Printed Name)

(Address)

(Social Security Number )

(Daytime Telephone Number)

(E-Mail Address, if Applicable)

Certifying Officer - The individual must sign in your presence. You must complete the certification and affix your stamp or seal.

I CERTIFY that

, whose identity is known or was

proven to me, personally appeared before me this

day of

,
(Month)

,
(Year)

, and signed this form.

at
(City)

(State)
(Signature and title of certifying officer)

(OFFICIAL STAMP
OR SEAL)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

Continuation of description of securities in Item 1:
TITLE OF SECURITY

ISSUE
DATE

FACE/PAR
AMOUNT

BOND NO. OR ACCOUNT NO.

REGISTRATION

(If more space is needed, use a continuation sheet and attach it to the form.)

INSTRUCTIONS
USE OF FORM – Use this form to disclaim your right, title, and interest to United States Treasury Securities and consent to
the payment, refund of purchase price, transfer, reissue, or other disposition of them by another person.
A minor or person under legal disability may not complete this form.
ATTACHMENTS – If more space is needed for any item, use a plain sheet of paper and attach to the form.
COMPLETION OF FORM – Print clearly in ink or type all information requested.
ITEM 1. Describe the securities.
ITEM 2. Show the name and address of the person to whom you are conveying your interest in the securities. Give
the reason(s) you are disclaiming your right, title, and interest in the securities and consenting to the
payment, refund of purchase price, transfer, reissue, or other disposition of them by another person.
ITEM 3. You must sign the form in ink, print your name, and provide your home address, social security number,
daytime telephone number, and, if applicable, e-mail address. Your signature must be certified (see
CERTIFICATION below).
CERTIFICATION – You must appear before and establish identification to the satisfaction of an authorized certifying officer
and sign the form in the officer’s presence. The certifying officer must fully complete the certification form provided and affix
the seal or stamp which is used when certifying requests for payment. Authorized certifying officers are available at most
financial institutions, including credit unions. For a complete list of such officers, see Department of the Treasury Circulars,
Nos. 300 and 530, or Public Debt Series, Nos. 3-80 and 2-98.
WHERE TO SEND – Unless otherwise instructed in accompanying correspondence, send the completed form and the
securities, if any, as well as any other evidence and forms to the Department of the Treasury, Bureau of the Public Debt,
using the addresses listed below:
Definitive (paper) savings bonds – PO Box 7012, Parkersburg, WV 26106-7012.
Marketable securities – PO Box 426, Parkersburg, WV 26106-0426.

PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
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 06 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 address shown in "WHERE TO
SEND" above.
(2)

PD F 1849