Form PD F 1455 PD F 1455 Request By Fiduciary For Distribution Of United States T

RESET
For official use only:
Customer Name

Customer No.

PD F 1455 E
Department of the Treasury
Bureau of the Public Debt
(Revised June 2008)

REQUEST BY FIDUCIARY FOR DISTRIBUTION OF
UNITED STATES TREASURY SECURITIES

OMB No. 1535-0012

Visit us on the Web at www.treasurydirect.gov
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

One or more fiduciaries (individual or corporate) must use this form to establish entitlement and request distribution of United States
Treasury Securities and/or related payments to the person lawfully entitled (e.g., termination of trust, distribution of an estate, attainment
of majority, restoration to competency).
PART A – REASON FOR DISTRIBUTION
I/We request distribution of the securities and/or related payments for the following reason:
Termination of trust
Distribution of an estate
Payment to the estate (Fiduciary must sign the back of the bonds or submit a PD F 1522)
Reissue to the estate
Distribution to person(s) entitled*
*If payment is requested by person(s) entitled a PD F 1522 is required.
If reissue is requested by person(s) entitled a PD F 4000 is required.
Attainment of majority
Restoration to competency
Other: __________________________________
PART B – DISTRIBUTION OF SECURITIES AND PAYMENTS
I/We request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)
OR
(Social Security Number)

(Employer Identification Number)
(Address and Telephone Number)

2. Description of securities and/or related payments:
TITLE OF SECURITY

3. Extent of distribution:

ISSUE
DATE

FACE AMOUNT

IDENTIFYING NUMBER

In full
(Amount, Fractional Share, or Percentage)

REGISTRATION

PART B – DISTRIBUTION OF SECURITIES AND PAYMENTS (Continued)
I/We request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)
OR
(Social Security Number)

(Employer Identification Number)

(Address and Telephone Number)

2. Description of securities and/or related payments:
TITLE OF SECURITY

3. Extent of distribution:

ISSUE
DATE

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

In full
(Amount, Fractional Share, or Percentage)

I/We request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)
OR
(Social Security Number)

(Employer Identification Number)

(Address and Telephone Number)

2. Description of securities and/or related payments:
TITLE OF SECURITY

3. Extent of distribution:

ISSUE
DATE

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

In full
(Amount, Fractional Share, or Percentage)

(2)

PD F 1455

PART C - SIGNATURES AND CERTIFICATIONS
I/We certify under penalty of perjury that the information provided herein is true and correct to the best of my/our knowledge
and belief and agree to distribution of the securities as indicated in Part B. I/We bind ourselves, our heirs, legatees, successors
and assigns, jointly and severally, to hold the United States harmless on account of the transaction requested, to indemnify
unconditionally and promptly repay the United States in the event of any loss which results from this request, including interest,
administrative costs, and penalties. I/We consent to the release of any information regarding this transaction, including information
contained in this application, to any party having an ownership or entitlement interest in the securities or payments.
You must wait until you are in the presence of a certifying officer to sign this form.

Sign Here: ⇒
(Applicant's Signature)

(Applicant’s Title)

(Number and Street, Rural Route, or PO Box)

(City)

(Daytime Telephone Number)

(State)

(ZIP Code)

(E-Mail Address)

Sign Here: ⇒
(Applicant's Signature)

(Applicant’s Title)

(Number and Street, Rural Route, or PO Box)

(City)

(Daytime Telephone Number)

(State)

(ZIP Code)

(E-Mail Address)

Certifying Officer - The individuals 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)
ACCEPTABLE CERTIFICATIONS: Financial Institution’s
Official Seal or Stamp (Such as Corporate Seal, Signature
Guaranteed Stamp, or Medallion Stamp).

(Number and Street or Rural Route)
(City)

(State)

I CERTIFY that

(ZIP Code)

, 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)
ACCEPTABLE CERTIFICATIONS: Financial Institution’s
Official Seal or Stamp (Such as Corporate Seal, Signature
Guaranteed Stamp, or Medallion Stamp).

(Number and Street or Rural Route)
(City)

(3)

(State)

(ZIP Code)

PD F 1455

INSTRUCTIONS
USE OF FORM – One or more fiduciaries (individual or corporate) must use this form to establish entitlement and request
distribution of United States Treasury Securities and/or related payments to the person lawfully entitled (e.g., termination
of trust, distribution of an estate, attainment of majority, restoration to competency).
If more space is needed for any item, use a plain sheet of paper or make photocopies, as necessary, and attach to the
form.
PART A – REASON FOR DISTRIBUTION
Mark the box to show the reason for the distribution. If you mark “Other,” describe the reason.
Submit a copy of all evidence that establishes your authority to request this transaction. For example, if you are
the administrator or executor of an estate, provide a certified copy of your letters of appointment, dated within one
year of submission. Submit certified copies of death certificates for all deceased registrants.
PART B – DISTRIBUTION OF SECURITIES AND PAYMENTS
Complete Items 1 through 3.
1. Enter the name of only one distributee in each Part B, Item 1. (A separate Part B must be completed for each
distributee.) Enter the appropriate social security number or employer identification number.
2. Describe only the securities and/or checks which the person shown in Item 1 is to receive, in whole or in part:
TITLE OF SECURITY – Identify each security by series, interest rate, type, CUSIP, call and maturity date, as appropriate.
If describing a check, insert the word “check.”
ISSUE DATE – Provide the issue date of each security or check.
FACE AMOUNT – Provide the face amount (par or denomination) of each security or check.
IDENTIFYING NUMBER (if applicable) – Provide the serial number of each security, the confirmation number, or the
check number.
REGISTRATION – Provide the registration of each security, check, or account; also provide the account number, if any.

EXAMPLES:

TITLE OF SECURITY

ISSUE
DATE

FACE AMOUNT

5/15/79

$5,000

Paper Marketable Security

9 1/8 % TREASURY BOND OF
2004-2009 MATURES 5/15/09
CUSIP 912810CG1
Electronic Marketable Security

CUSIP 912795QW4

Electronic Series I Savings Bond

SERIES I

Paper Series EE Savings Bond

SERIES EE

Check

CHECK

IDENTIFYING NUMBER
Serial #

2/5/04

$1,000

1/1/02

$100

7/99

$100

7/26/04

$351.02

123

REGISTRATION
JOHN DOE AND JANE DOE
SSN 222-22-2222
ACCT # 4800-123-1234
JOHN DOE
SSN 222-22-2222

Confirmation #

12345
Serial #

C-123,456,789-EE

ACCT # N-111-11-1111
JOHN DOE
SSN 222-22-2222
JOHN DOE
OR JANE DOE

Check #

502123456

JOHN DOE

If unsure what to provide in each of the areas, furnish all identifying information in the space for REGISTRATION.

3. Mark the box “In full” if the person listed in Item 1 is to receive the entire value of the securities and/or checks described
in Item 2; or if the person listed in Item 1 is not to receive the entire value, mark the second box and provide the
appropriate amount, fractional share, or percentage he/she is to receive.

Part B continued next page
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PD F 1455

PART B – DISTRIBUTION OF SECURITIES AND PAYMENTS (Continued)
In most cases, we will need additional forms and/or information from the distributee. If so, we may contact the
distributee directly. If the transaction can be processed without additional forms or information from the distributee, we
will send the securities and/or payments directly to the distributee.
Note: If the distributee wants payment of eligible paper securities and the securities are:
Savings bonds or notes, he/she must complete the request on the reverse of the bond.
Marketable securities, the fiduciary must complete the assignment on the reverse of the security. The
distributee must complete IRS Form W-9.
Any interest that is or becomes due on securities belonging to the estate of the decedent will be paid to the person to whom
the securities are distributed, unless otherwise requested.
PART C – SIGNATURES AND CERTIFICATIONS
SIGNATURES – The application must be signed in ink. Sign the form in your fiduciary capacity. If the request is on behalf
of a corporate fiduciary, the name of the corporation must be given, followed by the signature and title of an authorized
officer. If there are two or more fiduciaries, all must join in the request unless by express statute, decree of court, or the
terms of the instrument under which the fiduciaries are acting, one or more of them may properly execute the request.
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 most financial institutions, including credit unions.
Sample certification for a financial Institution:

Acceptable certification for a brokerage:

SIGNATURE GUARANTEED

SIGNATURE GUARANTEED

ABC National Bank

MEDALLION GUARANTEED

Hillview Branch

Generic Brokerage

Authorized Signature

Authorized Signature
XXXXXXXX
SECURITIES TRANSFER AGENTS MEDALLION PROGRAM
[Bar Code]

ADDITIONAL EVIDENCE – The Commissioner of the Public Debt, as designee of the Secretary of the Treasury, reserves
the right in any particular case to require the submission of additional evidence.
RETURN OF EVIDENCE – If you want the evidence submitted with this form returned to you, please provide a written
request when you submit the form and evidence.
WHERE TO SEND – Unless otherwise instructed in accompanying correspondence, send to the Department of the
Treasury, Bureau of the Public Debt, using the address listed below:
Definitive (paper) savings bonds – PO Box 7012, Parkersburg, WV 26106-7012
Book entry savings bonds – PO Box 7015, Parkersburg, WV 26106-7015
Series H or Series HH Savings Bonds – PO Box 2186, Parkersburg, WV 26106-2186
All marketable securities– PO Box 426, Parkersburg, WV 26106-0426
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 furnishing 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 30 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 this address; send to the correct address shown in "WHERE TO SEND" in the instructions.

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PD F 1455