Form PD F 5336 PD F 5336 Disposition Of Treasury Securities Belonging To A Decend

For official use only:
Customer Name

Customer No.

PD F 5336 E
Department of the Treasury
Bureau of the Public Debt
(Revised April 2008)

DISPOSITION OF TREASURY SECURITIES BELONGING TO A DECEDENT’S
ESTATE BEING SETTLED WITHOUT ADMINISTRATION

OMB No. 1535-0118

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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

A person qualified by the Department of the Treasury to act as voluntary representative must use this form to request disposition of
United States Treasury Securities and/or related payments belonging to a decedent’s estate that is not being administered. See the
instructions for the definition of a voluntary representative. If the decedent’s securities and/or related payments are worth over $100,000
redemption and/or par value as of the date of death, Treasury regulations require that the estate be administered through the court; in
this event, this form may not be used.

WHERE TO SEND – Unless otherwise instructed in accompanying correspondence, send this form, all securities and/or related checks,
and any necessary evidence to: 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
All marketable securities and electronic savings bonds – PO Box 426, Parkersburg, WV 26106-0426
Definitive (paper) savings bonds and marketable or electronic savings bonds – PO Box 426, Parkersburg, WV 26106-0426
Carefully read the instructions before completing this form.

PART A – ESTATE INFORMATION
Provide the information below and submit certified copies of the death certificates for all deceased registrants.

(Name of Deceased Owner - If more than one person named on the securities, the person who died last)

(Decedent’s Social Security Number)

(Jurisdiction of Legal Residence)

By signing this form, I certify that a legal representative has not been and will not be appointed through the court and that the estate will
not be settled in accordance with the law of the decedent’s domicile (such as Summary Administration, Small Estates Act, Texas
Muniment of Title, Louisiana Judgment of Possession, etc.).
If the above statement does not apply, do not complete this form. Instead, send the securities and all evidence and/or documentation
concerning the estate to the address shown in “WHERE TO SEND” above.

PART B – PERSON QUALIFIED TO ACT AS VOLUNTARY REPRESENTATIVE
Title 31, Code of Federal Regulations (CFR), provides that to be qualified to act as voluntary representative, a person must be competent
and eighteen years of age or older and be eligible according to the Order of Precedence for Voluntary Representative shown below.
Carefully read the instructions before completing this Part.

Mark the box that represents your eligibility to act as voluntary representative.
Order of Precedence for Voluntary Representative
I am the surviving spouse
I am a child of the decedent and there is no surviving spouse
I am a descendant of a deceased child of the decedent and there are none of the above
I am a parent of the decedent and there are none of the above
I am a brother or sister of the decedent and there are none of the above
I am a descendant of a deceased brother or sister of the decedent and there are none of the above
I am next of kin of the decedent as determined by the law of the jurisdiction in which the decedent was domiciled
at the date of death and there are none of the above

PART C – TYPE OF DISPOSITION
As voluntary representative, you may request one of the following (mark the appropriate box):
Payment to yourself as voluntary representative on behalf of all persons entitled to share in the decedent’s estate. (Continue to Part D.)
Distribution of securities and/or related payments to the persons entitled according to the law of the jurisdiction in which the decedent
was domiciled at the date of death. (Skip to Part E.)
PART D – PAYMENT TO VOLUNTARY REPRESENTATIVE
I request that payment of the securities and/or related payments be made to me as voluntary representative.

1. Pay
to:
(Name)

(Social Security Number)
(Mailing Address)

2. Description of securities and/or related payments:
ISSUE
DATE

TITLE OF SECURITY

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

3. Mark the box for the particular type of security involved:
Book-Entry Savings Bonds (electronic issue held in
TreasuryDirect®) (Series E, EE and I)

Marketable Treasury Bills, Notes, Bonds, and TIPS (paper issue or
electronic issue held in Legacy Treasury Direct or TreasuryDirect)

Payment by Direct Deposit

Sell the unmatured security on my behalf (Payment will be made by
Direct Deposit; additional forms will be necessary)

Savings Bonds or Notes (paper issue only)
(Series A-D, E, EE, F, G, H, HH, I, J, & K))

Payment of the matured definitive (paper) security by check
Payment of the matured Book-Entry (electronic) security held in
Legacy Treasury Direct or TreasuryDirect by Direct Deposit

Payment by check
Payment by Direct Deposit

Payment of the matured Book-Entry (electronic) security held in
Legacy Treasury Direct by check
Direct Deposit funds as authorized below:
(Name/Names on the Account)
Type of Account:

Checking

Savings

(Depositor's Account No.)
Financial Institution Routing No.:

–

–

(Financial Institution's Name)

(Phone No.)

(If you completed Part D to receive payment as voluntary representative, do not complete Part E. Skip to Part F.)
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PD F 5336

PART E – DISTRIBUTION OF SECURITIES AND/OR RELATED PAYMENTS TO PERSON ENTITLED
I request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)

(Social Security Number)

(Mailing Address)
(Phone Number)

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

3. Extent of distribution:

ISSUE
DATE

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

Amount, Fractional Share, or Percentage

In full

PART E – DISTRIBUTION OF SECURITIES AND/OR RELATED PAYMENTS TO PERSON ENTITLED
I request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)

(Social Security Number)

(Mailing Address)
(Phone Number)

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

3. Extent of distribution:

ISSUE
DATE

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

Amount, Fractional Share, or Percentage

In full
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PD F 5336

PART F - SIGNATURE AND CERTIFICATION
I certify under penalty of perjury that the information provided herein is true and correct to the best of my knowledge and belief and that I
am eligible to act as voluntary representative. I further certify that I will distribute payment made to me as voluntary representative or that
I am distributing the securities and/or related payments to the persons entitled by the law of the jurisdiction in which the decedent was
domiciled at the date of death. The United States is not liable to any person for the improper distribution of payments or securities. Upon
payment or distribution of the securities at my request as voluntary representative, the United States is released to the same extent as if it
had paid or delivered to a representative of the estate appointed pursuant to the law of the jurisdiction in which the decedent was
domiciled at the date of death.
I bind myself, my 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 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, As Voluntary Representative of the
Decedent’s Estate)

(Daytime Telephone Number)

Address:
(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

E-Mail Address:
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)

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 the above
address; send to the address shown in the instructions.

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PD F 5336

INSTRUCTIONS
USE OF FORM – A voluntary representative is a person qualified by the Department of the Treasury to request disposition
of United States Treasury Securities (Treasury Bills, Notes, Bonds, TIPS, Savings Bonds and Savings Notes) and/or
related payments (not exceeding $100,000) that belong to a decedent’s estate if the estate is not being administered
through the court. A voluntary representative of the decedent’s estate must complete this form to request:
Payment on behalf of persons entitled to the estate according to the law of the jurisdiction in which the decedent
was domiciled at the date of death, or
Distribution of the securities to the persons entitled to the estate according to the law of the jurisdiction in which the
decedent was domiciled at the date of death.
If more space is needed for any item, use a plain sheet of paper or make photocopies, as necessary, and attach to the
form.
All securities belonging to the decedent’s estate must be included in this transaction. If the redemption and/or par value
of all securities and/or related payments owned by the decedent as of the date of death exceeds $100,000, Treasury
regulations require that the estate be administered through the court; in this event, this form may not be used.

PART A – ESTATE INFORMATION
Provide the requested information regarding the decedent. If more than one deceased person is named on the securities,
provide the information for the person who died last. Submit certified copies of the death certificates for all deceased
registrants.

Insert the following information:
Decedent’s name
Decedent’s social security number
Jurisdiction (state, district, or territory) of decedent’s last legal residence

By signing this form you certify that the decedent’s estate has not been and will not be administered through a court or
settled in accordance with the law of the decedent’s domicile (such as Summary Administration, Small Estates Act, Texas
Muniment of Title, Louisiana Judgment of Possession, etc.). If a legal representative has been appointed by the court, if
the estate has been administered and is now closed, or if you have a document establishing entitlement to the estate
(other than an unprobated will), do not complete this form. Instead, send the securities and all evidence and/or
documentation concerning the estate to the address shown in “WHERE TO SEND” on the last page of these
instructions. Upon review of the submission, we will provide additional instructions, if necessary.

PART B – PERSON QUALIFIED TO ACT AS VOLUNTARY REPRESENTATIVE
Title 31, Code of Federal Regulations (CFR), provides that disposition of a decedent’s estate that is not being administered
through the court will be made upon the request of a person qualified to act as voluntary representative. To act as
voluntary representative, you must be competent and eighteen years of age or older and be eligible according to the Order
of Precedence for Voluntary Representative.
Starting at the top, read down the Order of Precedence until you find the situation that applies to you. Mark the box that
represents your eligibility to act as voluntary representative. For example, if the decedent leaves a surviving spouse and
children (over the age of eighteen), the surviving spouse must complete this form. If there is no surviving spouse, one of the
children (over the age of eighteen) must complete this form.

PART C – TYPE OF DISPOSITION
Title 31, Code of Federal Regulations (CFR), provides that a voluntary representative may request one of the following:
Payment to the voluntary representative on behalf of all persons entitled to share in the decedent’s estate.
Distribution of securities and/or related payments to the persons entitled according to the law of the jurisdiction in
which the decedent was domiciled at the date of death.
Mark the appropriate box. If you are requesting payment, continue to Part D. If you are requesting distribution, skip Part D
and continue to Part E.

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PD F 5336

PART D – PAYMENT TO VOLUNTARY REPRESENTATIVE
Complete this part to receive payment as voluntary representative.

A person acting as voluntary representative who receives payment of securities and/or related payments warrants, certifies,
and unconditionally guarantees that he/she will make distribution of the proceeds to the persons entitled by the law of the
decedent's domicile at the date of death. Payment to a voluntary representative is for the convenience of the United States
and does not determine ownership of the securities or their proceeds.
1. Provide your name, social security number, and mailing address.
Note: Your social security number may be used to report all of the interest earned to the Internal Revenue Service for Federal income
tax purposes. For Federal income tax information, see IRS Publication 550 or contact the IRS or your tax advisor.

2. Describe the securities and/or checks:
TITLE OF SECURITY – Identify each security by series, interest rate, type, CUSIP, and 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.
Note: If the taxpayer identification number is included in the registration but is masked (i.e. ***-**-1234), please be sure to
provide the entire number.
EXAMPLES:
TITLE OF SECURITY

ISSUE
DATE

FACE AMOUNT

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 #

5/15/79

$5,000

2/5/04

$1,000

1/1/02

$100

7/99

$100

123

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

Confirmation #

IAAAB
Serial #

C-123,456,789-EE

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

Check #

7/26/04

$351.02

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 appropriate box indicating the method of payment for the particular type of security involved. Note: If securities
are held in a TreasuryDirect account, payment must be made by Direct Deposit. Payment for matured electronic securities
held in a Legacy Treasury Direct account may be made by check or Direct Deposit. The only payment option for matured
definitive (paper) marketable securities is by check.
For payment by Direct Deposit, furnish the name(s) on the account, the account number, the type of account, and the
financial institution's name, the routing/transit number that identifies the institution, and the institution's phone number. You
may need to contact the financial institution to obtain the routing number.
(If you completed Part D to receive payment as voluntary representative, do not complete Part E. Skip to Part F.)

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PD F 5336

PART E – DISTRIBUTION OF SECURITIES AND/OR RELATED PAYMENTS TO PERSON ENTITLED
Complete this part to distribute the securities and/or related payments to the persons entitled.
A person acting as voluntary representative who distributes securities and/or related payments warrants, certifies, and
unconditionally guarantees that he/she is making distribution to the persons entitled by the law of the decedent's domicile at
the date of death.
1. Enter the name, social security number, address, and phone number of only one distributee in each Part E, Item 1. (A
separate Part E must be completed for each distributee.)
2. Describe only the securities and/or checks that the person shown in Item 1 is to receive, in whole or in part. See Item 2
in Part D for information on how to describe securities and/or checks.
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.
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:
Savings bonds or notes, he/she must complete the request on the reverse of the bond.
Marketable securities, the voluntary representative must complete the assignment on the reverse of the
security and 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 F – SIGNATURES AND CERTIFICATIONS
SIGNATURES – The application must be signed in ink.
CERTIFICATION – You must appear before and establish identification to the satisfaction of an authorized certifying officer.
The form must be signed in the officer’s presence. The certifying officer must affix the seal or stamp that is used when
certifying requests for payment. Authorized certifying officers are available at most financial institutions, including credit
unions.
ADDITIONAL REQUIREMENTS – 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 and/or the formal administration of
the estate.
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 this form, all securities and/or
related checks, and any necessary evidence to: 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
All marketable securities and electronic savings bonds – PO Box 426, Parkersburg, WV 26106-0426
Definitive (paper) savings bonds and marketable or electronic savings bonds – PO Box 426, Parkersburg, WV
26106-0426
Note: You must use only one form and describe all of the securities.

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PD F 5336