Form PD F 1522 E PD F 1522 E Special Form Of Request For Payment Of United States Sav

RESET

For official use only:
Customer Name

Customer No.

SPECIAL FORM OF REQUEST FOR PAYMENT OF
UNITED STATES SAVINGS AND RETIREMENT
SECURITIES WHERE USE OF A DETACHED
REQUEST IS AUTHORIZED

PD F 1522 E
Department of the Treasury
Bureau of the Public Debt
(Revised May 2009)
Visit us on the Web at
www.treasurydirect.gov

OMB No. 1535-0004
FOR OFFICIAL USE ONLY
TRANSFER MONTH & YEAR ____/____
FISCAL AGENT CODE ______________

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. DESCRIPTION OF BONDS
I am the owner or person entitled to payment of the securities described below, which bear the name(s) of

.
ISSUE DATE

SERIAL NUMBER

ISSUE DATE

SERIAL NUMBER

ISSUE DATE

SERIAL NUMBER

(If you need more space, use the continuation sheet on Page 3.)

2. REQUEST FOR PAYMENT
a check.
direct deposit.

I request that the described bonds be redeemed and payment be made in the form of
To the extent of:

(Complete this line only if partial redemption and reissue of the remainder is desired or if the signer is only entitled to a
portion of the bonds listed. See Item 2 in the Instructions.)

(Social Security Number of Payee)

OR

(Employer Identification Number of Payee)

3. DELIVERY INSTRUCTIONS (Read Item 3 in the Instructions before completing this section and complete only Item 3A or 3B.)
A. Please mail my redemption check to:
(Name)

(Number and Street or Rural Route)

(City)

(State)

B. Please deposit my funds directly, as authorized below:

(Name/Names on the Account)
Type of Account:

Checking

Savings

(Depositor's Account No.)
Bank Routing No.:

(Financial Institution's Name)

(Phone No.)

(ZIP Code)

4. SIGNATURE
You must wait until you are in the presence of a certifying officer to sign this form.
Sign Here:
(Signature)

(Print Name)

(Number and Street or Rural Route)

(E-mail Address)

Home Address

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

Sign Here:
(Signature)

(Print Name)

(Number and Street or Rural Route)

(E-mail Address)

Home Address

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

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
(Month)

,
(Year)

, and signed this form.

at
(City)

(State)
(Signature of Certifying Officer)

(OFFICIAL STAMP
OR SEAL)

(Title of Certifying Officer)
(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 of Certifying Officer)

(OFFICIAL STAMP
OR SEAL)

(Title of Certifying Officer)
(Number and Street or Rural Route)
(City)

(State)

(ZIP Code)

RESERVED FOR IDENTIFICATION NOTATIONS
Customer Account Number
and Date Established:

Document(s) - Description:

Identified by (Signature and Address):
INSTRUCTIONS TO CERTIFYING OFFICER
Each person appearing before you must establish identification by positive and reliable evidence before this form is signed, unless he or she is personally known
to you. Place an adequate notation above or on a separate record, showing exactly how identification was established. A notation is adequate if it is sufficiently
detailed to permit, at a later date, a determination of the exact identification actually used. You and the organization will be held fully responsible for the adequacy
of the identification.
The signatures to the request must be executed in your presence. Fully complete and sign the certification form provided for your use for each signature you
witness.
If you are an employee (rather than an officer) authorized to certify signatures, insert the words “Authorized Signature” in the space provided for the title. Insert
the place and date, as required on the form, and impress the seal of your organization.

2

PD F 1522 E

Continuation of description of bonds in Item 1:
ISSUE DATE

SERIAL NUMBER

ISSUE DATE

SERIAL NUMBER

ISSUE DATE

SERIAL NUMBER

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

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 15 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 correct address shown in "WHERE TO SEND" in the
instructions.

3

PD F 1522 E

INSTRUCTIONS
USE OF FORM – Use this form to request payment of United States Savings Bonds, Savings Notes, Retirement Plan
Bonds, and Individual Retirement Bonds.
WHO MAY COMPLETE – This form may be completed by the owner, coowner, surviving beneficiary, or legal
representative of the estate of a deceased or incompetent owner, persons entitled to the estate of a deceased registrant,
or such other persons who may be entitled to payment under the regulations governing United States Savings Bonds. A
minor may sign this form if, in the opinion of the certifying officer, he/she is of sufficient competency to understand the nature of
the transaction. (See CERTIFICATION below.) An incompetent person may not sign this form.

COMPLETION OF FORM – Print clearly in ink or type all information requested.
ITEM 1.

DESCRIPTION OF BONDS – Provide the name(s) of the person(s) shown in the inscription of the bonds for
which payment is requested. Describe the bonds by issue date and serial number. If more space is needed,
use the continuation sheet on Page 3. If additional space is needed, use a continuation sheet (PD F 3500)
and attach it to this form.

ITEM 2.

REQUEST FOR PAYMENT

•

Mark the appropriate box to indicate whether you want to be paid by check or direct deposit.

•

If the signer is entitled to a distributive share of the listed bonds or if partial redemption of bonds and reissue of
the remainder is desired, that fact must be shown on the line provided. Check the box "to the extent of" and
insert "$ _______ (face amount) and reissue of the remainder." If such bonds have not reached final maturity,
partial redemption at the current redemption value will be made in amounts corresponding to authorized
denominations and the remainder will be reissued showing the original issue date(s). If such bonds have
reached final maturity, partial redemption is not permitted and, in this event, full payment will be made.

•

The payee's Taxpayer Identification Number must be provided. Furnish the Social Security Number if the
payee is an individual. If an estate is involved and IRS has assigned an Employer Identification Number,
provide that number.

•

Please verify account information for accuracy and legibility to avoid a delay in deposit.

ITEM 3.

DELIVERY INSTRUCTIONS

•

If payment is to be made by check, furnish the name and address where the check is to be mailed in Item 3A.

•

For payment by Direct Deposit, complete Item 3B. Furnish the name(s) on the account, the account number,
the type of account, and the financial institution's name, the routing/transit number which identifies the
institution, and the institution's phone number. You may need to contact the financial institution to obtain the
routing number.

ITEM 4.

SIGNATURE – The person(s) requesting payment of the bonds must sign the form in ink, print his/her name,
and provide his/her address, daytime telephone number, and if applicable, e-mail address. If the name of a
person requesting payment has been changed by marriage or in any other legal manner from the name in the
inscription of the bonds, the signature to the request for payment must show both names and the manner in
which the change was made; for example, "Miss Mary T. Jones now by marriage Mrs. Mary T. Smith.” (See
CERTIFICATION below.)

CERTIFICATION – The person(s) requesting payment of the bonds must appear before and establish identification to the
satisfaction of an officer authorized to certify requests for payment of United States Savings Bonds and sign the request in
the presence of the officer. If a minor signs the forms, the officer must be satisfied that the minor is of sufficient
competency to understand the nature of the transaction. Authorized certifying officers are available at financial
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 Nos. 3-80 and 2-98.
WHERE TO SEND – Send the PD F 1522 E and the bonds, as well as any other appropriate forms and evidence, to one
of the Treasury Retail Securities Sites shown below:
Treasury Retail Securities Site
PO Box 299
Pittsburgh, PA 15230-0299
1-800-245-2804

Treasury Retail Securities Site
PO Box 214
Minneapolis, MN 55480-0214
1-800-553-2663

4

PD F 1522 E