PD F 5263-1 Order For Series EE U.S. Savings Bonds To Be Registered

PD F 5263-1 (11_08spot color)

PD F 5263-1
Department of the Treasury
Bureau of the Public Debt
(Revised November 2008)

1/14/09

2:40 PM

Page 1

OMB No. 1535-0084

ORDER FOR SERIES EE U.S. SAVINGS BONDS
TO BE REGISTERED IN NAME OF FIDUCIARY
PLEASE FOLLOW THE INSTRUCTIONS ON THE BACK. PRINT IN CAPITAL LETTERS.

1. FIDUCIARY REGISTRATION (Due to space restrictions on savings bonds, information printed below may be abbreviated by the
Federal Reserve Bank.)
Name

Social Security
Number

OR

Taxpayer ID
Number

2. NAME OF PERSON TO RECEIVE BONDS IF OTHER THAN FIDUCIARY ABOVE
Mail to:
3. ADDRESS WHERE BONDS ARE TO BE MAILED

(NUMBER AND STREET, RURAL ROUTE, OR POST OFFICE BOX)

(CITY OR TOWN)

(STATE)

4. COOWNER OR BENEFICIARY (Optional) The following person is to be named as

(ZIP CODE)

beneficiary:

coowner

Name
(Coownership will be assumed if neither or both blocks are checked.)
5. BONDS ORDERED
Denom.

Quantity

Issue Price

Total Issue Price

FOR AGENT USE ONLY

$

50

X$

25.00 = $

,

.

$

75

X$

37.50

=$

,

.

$

100

X$

50.00 = $

,

.

$

200

X$

100.00 = $

,

.

$

500

X$

250.00

=$

,

.

$

1,000

X$

500.00 = $

,

.

$

5,000

X $ 2,500.00 = $

,

.

$

10,000

X $ 5,000.00 = $

,

.

$

,

.

TOTAL ISSUE PRICE OF PURCHASE

AFFIXED AGENT STAMP CERTIFIES THAT
TOTAL AMOUNT OF PURCHASE IS CORRECT

6. DATE PURCHASE ORDER AND PAYMENT PRESENTED TO AGENT
(DAY)

(MO.)

(YR.)

7. SIGNATURE

PURCHASER’S SIGNATURE

(
PURCHASER’S NAME, IF OTHER THAN OWNER OR FIRST-NAMED COOWNER (Please print)
STREET ADDRESS (If not shown above)

)
DAYTIME TELEPHONE NUMBER

CITY

SEE INSTRUCTIONS FOR PRlVACY ACT AND PAPERWORK REDUCTION ACT NOTICE

STATE

ZIP CODE

PD F 5263-1 (11_08spot color)

1/14/09

2:40 PM

Page 2

INSTRUCTIONS FOR COMPLETING THE PURCHASE ORDER
1.

FIDUCIARY REGISTRATION. Clearly PRINT in block letters the name and title or capacity of the fiduciary (including legal
guardians and similar representatives, certain custodians, and trustees) followed by an appropriate reference to the
estate or the authority governing the trust. Show the social security account number of the ward or the taxpayer identifying number
assigned to the trust. A social security account or taxpayer number must be provided.
Examples Of
Authorized Registrations

Abbreviations To Be Used On
Purchase Order

Tenth National Bank guardian (or conservator, etc.) of
the estate of George N. Brown, a minor (or incompetent,
aged person, etc.).

Tenth Natl Bk gdn (or cons) est George N Brown an incomp
(or aged pers, etc.)

Tenth National Bank, trustee under agreement with
Paul E. White, dated 2/1/80.

Tenth Natl Bk Tr U/A Paul E White dtd 2-1-80

Carl A. Black and Henry B. Green, co-trustees under
agreement with Paul E. White, dated 2/1/80.

Carl A Black & Henry B Green Co-Tr U/A Paul E White
dtd 2-1-80

Paul E. White, trustee under declaration of trust dated
2/1/80.

Paul E White Tr U/D/T dtd 2-1-80

For complete information as to authorized forms of registration and restrictions, see Department Circular, Public Debt
Series No. 3-80.
2.

NAME OF PERSONS TO RECEIVE BONDS IF OTHER THAN FIDUCIARY ABOVE. After “Mail to:” print the name to whom the bonds
are to be mailed.

3.

ADDRESS WHERE BONDS ARE TO BE MAILED. In all cases, print the address where the bonds are to be mailed.

4.

COOWNER OR BENEFICIARY. You may not include a coowner or beneficiary on bonds issued in a trust form of registration.
You may, however, include a coowner or beneficiary on bonds that name as owner a minor or incompetent person who is
under legal guardianship, but only if the funds used to purchase the bonds do not belong to the minor or incompetent.
If you wish to name a coowner or beneficiary, check the appropriate box and print the person’s name.
If you name a coowner: The bonds may be cashed by the coowner or by the guardian (or conservator, etc.) of the estate of the minor
or incompetent.
If you name a beneficiary: The bonds may not be cashed by the beneficiary during the lifetime of the owner.

5.

BONDS ORDERED. Indicate next to the appropriate denomination the number of bonds being purchased; the total price
involved for each denomination (no. of bonds X issue price); and the total amount of purchase. If you fail to indicate the
denomination preferred, the fewest number of bonds which equal the total amount of purchase will be issued.

6.

DATE PURCHASE ORDER AND PAYMENT PRESENTED TO AGENT. Indicate the date on which the purchase order and
payment is presented (received) and accepted by the bank or other financial institution authorized to act as an agent of
the Treasury Department.

7.

SIGNATURE. Please sign this purchase order. Print your name and address if they don’t appear in the registration of
the bonds as shown in Sections 1 and 3. In order to promptly resolve any problems connected with this purchase order, also provide
a telephone number where you ordinarily may be reached Monday through Friday, from 9 a.m. to 5 p.m.

NOTE: Upon completion, submit purchase order and total amount of purchase to a financial institution authorized to sell U.S. Savings Bonds.
ALLOW ABOUT THREE WEEKS FOR PROCESSING.
NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
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 5 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; instead, send to a financial institution authorized to sell
U.S. Savings Bonds.