Form PD F 4239 PD F 4239 Request By Owner Or Person Entitled To Payment Or Reissu

RESET
For official use only:
Customer Name

Customer No.

PD F 0385 E
Department of the Treasury
Bureau of the Public Debt
(Revised October 2005)

OMB No. 1535-0048

CERTIFICATE OF IDENTITY

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 under the laws of the United States.

PRINT IN INK OR TYPE ALL INFORMATION

Affidavit
• I certify that the names

and

refer to the same person, whose correct name is

.

• Is there now or was there during

any other person known to you by either/any
(Date or Period of Time)

of these names?

Yes

No

If Yes, please explain:

• The names are different because:
• The source of my knowledge is:

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

Sign Here: ⇒
(Signature)
(Signature
of Applicant)

(Daytime Telephone Number)

Home Address:
(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

Certification – (Certifying Officer - The individual must sign in your presence. Complete the certification and affix your stamp or seal.)
I CERTIFY that
me this

, whose identity is known or proven to me, personally appeared before
day of

,
(Month)

, at
(Year)

, and signed this form.
(City)

(State)

(Signature and title of certifying officer)

(OFFICIAL STAMP
OR SEAL)

(Street address)
(City)

(State)

(ZIP Code)

INSTRUCTIONS
A person who has NO interest in the securities must complete and sign this form, confirming the individual's identity. Unless otherwise instructed in
accompanying correspondence, mail to the Treasury Retail Securities Site that requested this form or to the 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
CERTIFICATION
Person who signs form - You must sign the form in the presence of an officer authorized to certify assignments or requests for payment of
United States savings and retirement securities. Authorized certifying officers are available at financial institutions, including credit unions, in the
United States. For complete lists of such officers, see Department Circulars, Nos. 300 and 530, and Public Debt Series, Nos. 3-80 and 2-98.
Certifying officer - The person appearing before you must establish identification by positive and reliable evidence before this form is signed,
unless he/she is personally known to you. You must complete and sign the certification form and affix your organization's seal or stamp. If you
are an employee (rather than an officer) authorized to certify, insert the words “Authorized Signature” in the space provided for the title.
NOTICE UNDER PAPERWORK REDUCTION ACT
We estimate that it will take you about 10 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.