Form PD F 0974 E PD F 0974 E Affidavit Of Forgery For United States Savings Bonds

RESET
For official use only:
Customer Name

Customer No.

PD F 0974 E
Department of the Treasury
Bureau of the Public Debt
(Revised July 2007)

OMB No. 1535-0067

AFFIDAVIT OF FORGERY FOR
UNITED STATES SAVINGS BONDS

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. I,

,

, certify that I am the

(Name)

owner

coowner

(Social Security No.)

beneficiary of the following United States Savings Bonds totaling $

(face amount),

shown to have been redeemed at
, and the information below is true and complete to the best of my knowledge and belief.
REGISTRATION
ISSUE DATE

FACE AMOUNT

SERIAL NUMBER

(Provide complete Social Security Number [for example, 123-45-6789]
and names, including middle names or initials, on the bonds)

Check this box if additional bonds are described on a continuation sheet attached and made a part of this form.
2. Have you examined the photographs of the above-described bonds and do you certify that the signatures to the requests for
payment were forged and were made without your authority? YES
NO
If NO, explain:
3. Have you authorized any person to request payment of the bonds, present them for payment, or receive any of their value?
YES

NO

If YES, explain:

4. Have you received reimbursement because of the loss? YES

NO

If YES, explain:
5. Do you know of any person who may have taken the bonds, signed the requests for payment, cashed the bonds, or received any
of their value? YES
6.

NO

If YES, explain:

(a)

Where were the bonds kept at the time of loss or theft?

(b)

What was the location?
(Street and Number or Rural Route, City, and State)

7.

(c)

Who placed the bonds there?

(d)

Who else had access to the bonds?

(a)

When were the bonds lost or stolen?

(b)

What were the circumstances of the loss or theft?

8. Were any identification documents lost or stolen at the same time? YES

When?

NO

If YES, describe in detail:
9.

(a)

What action, to include the filing of a police report, was taken to recover the bonds?

(b)

What were the results of that action?

You must wait until you are in the presence of a certifying officer to sign this form.

Sign HereÖ
(Signature)

(Print Name)

(Number and Street or Rural Route)

(E-mail Address)

Home AddressÖ

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

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)

at

,
(Year)

, and signed this form.
(City)

(State)
(Signature and Title of Certifying Officer)

(OFFICIAL STAMP
OR SEAL)

(Number and Street or Rural Route)
(City)

(State)

(ZIP Code)

INSTRUCTIONS
USE OF FORM – This form may be used by the owner, coowner, or beneficiary to certify that the signatures to the requests for payment of
United States Savings Bonds were forged. Every question must be answered in detail and all possible information furnished.
ATTACHMENTS – If more space is needed for any item, use a plain sheet of paper and attach it to the form.
COMPLETION OF FORM
ITEM 1. Insert your name and social security number. Check the appropriate block to show whether you are the owner, coowner, or
beneficiary of the bonds bearing your alleged signature. Insert the total face amount of forged bonds, the location where they were
cashed, and a complete description of them.
ITEM 2. Mark the appropriate box to show if the signatures are forgeries and were made without your authorization. If the signatures were
made by you or by someone else with your consent, check the “NO” box and explain fully.
ITEM 3. Mark the appropriate box to show if you authorized anyone to take any action concerning the bonds. If “YES”, insert that person’s
name and address and show the extent of authority.
ITEM 4. Mark the appropriate box to show if you have received reimbursement because of the loss. If “YES”, state what reimbursement you or
anyone on your behalf received from any source. If anything of value has been received, give full details, including the name and
address of the person from whom or the organization from which it was received. If you have been promised reimbursement, give the
name and address of the person or organization who made the promise and explain clearly why this was done.
ITEM 5. Mark the appropriate box to show whether you have reason to believe any person had any connection with the loss, theft, or forgery of
the bonds. If “YES”, furnish the name and address of that person and give complete details, including the person's relationship to you.
ITEM 6. (a) and (b) Describe fully the place where the bonds were kept and show whether they were under lock and key. (If the bonds were
mailed to you and never received, state “Not Received” and skip to Item 8.) (c) State who placed the bonds there and the date. (d)
Furnish the names and addresses of all persons who had access to the bonds.
ITEM 7. State the date the loss or theft occurred, how it occurred, and who discovered the loss or theft.
ITEM 8. Mark the appropriate box to show if any identification documents were also lost or stolen. If “YES”, describe the documents, if any,
and show whether or not they bore your signature and/or contained your physical description or photograph.
ITEM 9. Explain what was done to recover the bonds, not only by you personally, but by any police, insurance, or similar agencies.
SIGNATURE – You must sign the form in ink, print your name, and provide your home address, daytime telephone number, and e-mail address, if
applicable. Your signature must be certified (see CERTIFICATION) below.
CERTIFICATION – You must appear before and establish identification to the satisfaction of an authorized certifying officer and sign the form 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 banking institutions, including credit unions. 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.
SUPPLEMENTAL EVIDENCE – If any person other than the person executing this affidavit had custody of the bonds at the time of loss or theft,
or has firsthand knowledge of the circumstances under which the bonds were lost, stolen, or forged, that person must furnish an affidavit
concerning his knowledge of the loss, theft, and/or forgery.
WHERE TO SEND – Send the completed form to the Department of the Treasury, Bureau of the Public Debt, PO Box 7014, Parkersburg,
WV 26106-7014.

NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
We're asking for the information on this form to assist us in processing your securities transaction requests. Our authority comes from 31 U.S.C. Ch. 31 which authorizes the
Treasury Department to borrow money to pay the public debt of the United States. Also, 26 U.S.C. 6109 requires us to use your SSN on certain forms when we report taxable
income to IRS. It's voluntary that you provide the requested information, but without it, we may not be able to process your transaction requests. Information concerning your
securities holdings and transactions is considered confidential under Treasury regulations (31 CFR Part 323) and the Privacy Act. However, the following routine uses of this
information may include disclosure to the following persons or entities: agents and contractors who help us manage the public debt; others entitled to the securities or payment;
agencies (including disclosure through approved computer matches) determining eligibility for benefits, finding persons we've lost contact with, or helping us collect debts;
agencies for investigations or prosecutions; courts, counsel, and others for litigation and other proceedings; a Congressional office asking on your behalf; and as otherwise
authorized by law.
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 261061328. DO NOT SEND completed form to the above address; send to the correct address shown in "WHERE TO SEND" above.

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PD F 0974