Form PDF-2513 Application By Voluntary Guardian of Incapacited Owner o

RESET
For official use only:
Customer Name

Customer No.

PD F 2513 E
Department of the Treasury
Bureau of the Public Debt
(Revised May 2008)

OMB No. 1535-0036

APPLICATION BY VOLUNTARY GUARDIAN OF
INCAPACITATED OWNER OF UNITED STATES BONDS/NOTES

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. Certificate of Qualification
, of full age and residing at

I,
(Name of Applicant)

, certify the following:
(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

is an adult;

The owner of the bonds,
(Name of Bond Owner)

;

His/Her Social Security Number is:
(Social Security Number)

;

He/She resides at:
(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

He/She is mentally incapacitated and can't handle his/her own affairs;
No legal guardian or similar representative has been appointed for the incapacitated person's estate by any court,
no person is otherwise qualified to act, and no qualification for such appointment is pending; and
The incapacitated person is the registered owner of, or the person entitled to, the United States Savings
Bonds/Notes listed in Item 2 below.
2. Description of Bonds
ISSUE DATE

BOND NUMBER

ISSUE DATE

BOND NUMBER

ISSUE DATE

BOND NUMBER

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

3. Nature of Request
I request that I be recognized as voluntary guardian of the incapacitated person, and in such capacity I further request:
A.

Payment of the above-listed bonds. I certify that the total redemption value of ALL bonds belonging to the incompetent at the
time of this application does not exceed $20,000.

B.

Reinvestment of matured Series E bonds for Series EE bonds. Any proceeds not reinvested will be used for the incapacitated
person's benefit. (PD F 5263 must be completed and submitted.)

C.

Payment of interest due or payable on any current income bonds, Series H or HH listed above. I agree that I will notify Public
Debt if the incapacitated person dies or is restored to competency, or if a legal guardian or similar representative of the
incapacitated person's estate is appointed or otherwise legally qualified.

D.

Issuance of substitutes for the above-described bonds upon my application and submission of satisfactory proof of loss, theft,
or destruction. (PD F 1048 must be completed and submitted.)

E.

Release of confidential information on savings bonds/notes on which the incapacitated person is named owner or coowner, or
to which he/she has become entitled.

4. Supporting Information
In support of the above request(s), I declare that my answers to the following questions and the other information given below are true
and complete, to the best of my knowledge and belief.
A.

(1) What is your relationship to the incapacitated person?
(2) Are you contributing to his/her care and support?

YES

NO

(3) Are any other persons or agencies contributing?

YES

NO

If YES, what are their names and addresses?

NAME

B.

ADDRESS

Describe the incapacitated person's disability:
YES

Has he/she been declared mentally incompetent by a court or governmental agency?

NO

(Proof of incompetency is required – see Item 4B in the Instructions.)
C.

Is the incapacitated person a patient in a hospital or other institution operated by a federal, state, or other governmental agency?
YES
NO
If YES, furnish the agency's name and address:

D.

Does the incapacitated person own any United States Savings Bonds/Notes in addition to those described on this form?
YES
NO If YES, list the additional holdings by issue date, face amount, serial number, and registration on a separate
sheet of paper and attach it to this form.

5. Signatures and Certification
Applicant - You must wait until you are in the presence of a certifying officer to sign this form.
I petition the Secretary of the Treasury for completion of the transactions requested above as authorized by law, and if such requests
are granted, hereby acknowledge and agree that the proceeds will be used for the benefit and support of the incapacitated person.
Upon approval of the requested transactions, I bind myself, my heirs, executors, administrators, successors and assigns, jointly and
severally, to hold the United States harmless as the result of any claim by any other parties having, or claiming to have, interests in the
bonds/notes and, upon demand by the Department of the Treasury, to indemnify unconditionally the United States and to repay the
Department of the Treasury all sums of money which the Department may pay to me as voluntary guardian, including any interest,
administrative costs and penalties, or losses incurred as a result of such payment. I declare under penalty that I have not knowingly
furnished any false, fictitious, or fraudulent information.

Sign Here:
(Signature of Applicant)

(Social Security Number)

(Type or Print Name)

(Daytime Telephone Number)

(E-Mail Address)

Certifying Officer – The individual must sign in your presence. 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

,

,
(Year)

(Month)

, and signed this form.

at
(City)

(State)
(Signature and title of certifying officer)

(OFFICIAL STAMP
OR SEAL)

(Street address)

(City)

(State)

(ZIP Code)

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PD F 2513

Consents of other contributors - You must wait until you are in the presence of a certifying officer to sign this form.
I (We) consent to the action(s) requested in this application.
Sign here:

Sign here:
(Signature)

(Signature)

(Number and Street or Rural Route)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

(City)

Sign here:

(State)

(ZIP Code)

Sign here:
(Signature)

(Signature)

(Number and Street or Rural Route)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

(City)

(State)

(ZIP Code)

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

and

, whose identities are known or were

proven to me, personally appeared before me this

day of

,

,
(Year)

(Month)

, and signed this form.

at
(City)

(State)
(Signature and title of certifying officer)

(OFFICIAL STAMP
OR SEAL)

(Street address)

(City)

I CERTIFY that

(State)

and

(ZIP Code)

, whose identities are known or were

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)

(Street address)

(City)

(State)

(ZIP Code)

PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
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 furninish 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 of 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 20 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 261061328. DO NOT SEND completed form to the above address; send to the address shown in "WHERE TO SEND" in the instructions.

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PD F 2513

INSTRUCTIONS
USE OF FORM – Use this form to request transactions involving United States Savings Bonds/Notes owned by a mentally incapacitated person for
whose estate no legal guardian or similar representative has been or is to be appointed or is otherwise qualified, for the following purposes:
•
•

To apply for payment if the value of all of the owner's bonds/notes does not exceed $20,000 and the proceeds will be used for the benefit and
support of the incapacitated person. The redemption value of the bonds/notes will be determined as of the date the request is received by the
Bureau of the Public Debt.
To apply for reinvestment of matured Series E .

•

To apply for payment of interest due on any current income savings bonds (Series H/HH) registered in the incapacitated person’s name.

•

To apply for substitute bonds on behalf of an incapacitated owner on account of the loss, theft, or destruction of the originals.

•

To apply for authority to receive confidential information to which the incapacitated person is entitled.

WHO MAY APPLY – Any relative who is actually supporting or otherwise looking after the affairs of the incapacitated person may apply or, if none,
anyone who is a proper person to represent the incapacitated person's interests may apply.
COMPLETION OF FORM – Answer all questions and furnish all information called for. If you need more space for any item, use a plain sheet of paper
and attach it to the form. Complete and attach any additional form necessary for the requested transaction.
ITEM 1. Furnish all information requested pertaining to yourself and the incapacitated person.
ITEM 2. List those savings bond/notes to which the application relates by issue date and bond number. Furnish information as to any other savings
bonds/notes owned by the incapacitated person on a separate sheet.
ITEM 3. Mark the appropriate box(es) to indicate the nature of your request.
A. PAYMENT - Mark this box to request payment of the incapacitated person's bonds/notes. The total redemption value of all bonds/notes
owned at the time of this application can't exceed $20,000. If the total redemption value of all bond/notes exceeds $20,000, this form
must not be used to request payment; instead, a legal representative must be appointed for the incapacitated person by the court having
jurisdiction. If the bonds to be redeemed have been lost, stolen, or destroyed, a PD F 1048 must also be completed and submitted.
B. REINVESTMENT - Mark this box for reinvestment of matured Series E bonds for Series EE bonds. In applying for a reinvestment
authorized by the governing regulations, the new bonds must be registered in the name of the incapacitated person followed by words
showing voluntary guardianship, for example, "123-45-6789 John Jones under voluntary guardianship." A living coowner or beneficiary
named on the bonds surrendered in the reinvestment transaction must be designated on the new bonds unless that person is a
competent adult and he/she furnishes a certified statement consenting to the omission of his/her name. The rules and regulations in
Department Circular, Public Debt Series No. 1-80 and on the applicable form, PD F 5263, must be followed. If the bonds to be
reinvested have been lost, stolen, or destroyed, a PD F 1048 must also be completed and submitted.
C. PAYMENT OF INTEREST - Mark this box for payment of interest on current income savings bonds (Series H/HH) now owned by the
incapacitated person. You must agree that the interest now due or payable will be used for the benefit and support of the incapacitated
person. You must also agree to notify Public Debt promptly if there is a change in the status of the incapacitated person. Interest on
current income bonds must be paid by Direct Deposit to the owner's account at a financial institution. You must complete a Direct
Deposit form, PD F 5396 or SF 1199A, and submit it with this application. Forms SF 1199A are available at financial institutions in the
United States. PD F 5396 is available for download on the Internet using the "forms" link at the address www.treasurydirect.gov. The
financial institution designated to receive the payment can assist in the completion of the Direct Deposit form.
D. MISSING BONDS - Mark this box If you wish to obtain substitutes for bonds which have been lost, stolen, or destroyed. You must also
complete a PD F 1048, as voluntary guardian, and submit it with this application. If any other person is named on the bonds, he/she
must join in signing the PD F 1048.
E. CONFIDENTIAL INFORMATION - Mark this box If you wish to obtain information on savings bonds/notes on which the incapacitated
person is named owner or coowner, or to which he/she has become entitled.
ITEM 4.

A. CONTRIBUTION – Show whether or not you are contributing to the incapacitated person's support. If other persons are also contributing
to the incapacitated person's care and support, their consents must be secured if payment is being requested under Item 3A on page 1.
Consent must be given in Item 5.
B. PROOF OF INCOMPETENCY - If a court has declared the bond owner legally incompetent to manage his/her affairs, you must furnish a
copy of the court order, certified under seal of the court. If no such determination has been made, a statement must be furnished from
the incapacitated person's attending physician, on the physician's professional stationery, describing briefly the bond owner's condition
and indicating whether or not he/she is mentally competent to engage in business transactions. If the incapacitated person is a patient in
a public institution, this statement may be made by the chief medical officer on the institution's official stationery.
C. CONSENT OF PUBLIC AUTHORITIES - If the incapacitated person is a patient in a hospital or other institution operated by a federal,
state, or other governmental authority, and a charge is or may be made for the care given, the governmental agency must furnish a
statement on official stationery by an authorized official having the duty to fix or collect such charge, consenting to the action requested.
Such consent is only required if payment is requested under Item 3A on page 1.
D. INCOMPETENT’S OTHER HOLDINGS - If the incapacitated person owns United States Savings Bonds/Notes other than those listed in
Item 2 on this application, describe the additional bonds/notes by serial number, issue date, denomination, and registration on a separate
sheet of paper and submit it with this application. This information is only required if payment is requested under Item 3A on page 1.

ITEM 5. Sign the form in ink, print your name, and provide your address, daytime telephone number, and e-mail address, if applicable. The application
must also be signed by contributors, if any. All signatures to the form must be properly certified. (See CERTIFICATION below.) If it is
inconvenient for the contributors to join in the application, their consents may be furnished on separate sheets of paper. The consents must
be worded to refer specifically to the action being requested and must be properly signed and the signatures certified.
CERTIFICATION – Each person whose signature is required must appear before and establish identification to the satisfaction of an authorized certifying
officer. The signatures to the form must be signed in the officer's presence. The certifying officer must affix the seal or stamp which is used when
certifying requests for payment. 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 Circulars, No. 530 and Public Debt Series No. 3-80.
WHERE TO SEND – Send the application and any supporting evidence to the Department of the Treasury, Bureau of the Public Debt, PO Box 7012,
Parkersburg, WV 26106-7012. If payment or reinvestment is requested, the bonds must be submitted with the application.

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PD F 2513