Form PD F 4000 PD F 4000 Request to reissue United States Savings Bonds

RESET
For official use only:
Customer Name

Customer No.

PD F 4000 E
Department of the Treasury
Bureau of the Public Debt
(Revised July 2006)

OMB No. 1535-0023

REQUEST TO REISSUE UNITED STATES SAVINGS BONDS
Visit us on the Web at www.treasurydirect.gov

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

PART A – NEW BOND REGISTRATION
1. Bond Description
I/We request reissue of the bonds described below, in the amount of $
ISSUE DATE

2. Extent of reissue:

FACE AMOUNT

BOND NUMBER

(total face amount).
REGISTRATION
(Social security number and names,
including middle names or initials, on the bonds)

Amount, Fractional Share, or Percentage

In full

3. Requested Registration
a. Taxpayer Identification Number:
(Social Security Number or Employer Identification Number)

b. Registration:
(First Name, Middle Name or Initial, Last Name or Fiduciary Inscription)

c. Address:
(Number and Street or Rural Route)

(City)

d. To name a coowner or
beneficiary, complete the
following:
coowner
beneficiary (POD)
(If a name is shown and neither
box is marked, coownership will
be assumed.)

(State)

(ZIP Code)

}
(First Name, Middle Name or Initial, Last Name)

4. Delivery instructions, if
different from above:

(Name)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

PART B – REASON FOR REISSUE
Describe the reason for the reissue.
If the reason shown above is to correct an error in registration, provide the following information.
(1) Who purchased the bonds?
(2) Whose funds were used?
(3) How did the error occur?

PART C – SIGNATURES AND CERTIFICATIONS
I/We certify under penalty of perjury that the information provided herein is true and correct to the best of my/our
knowledge and belief. I/We agree to reissue of the bonds as indicated in Part A and certify that the reissue is authorized.
I/We hereby bind ourselves, our heirs, legatees, successors and assigns, jointly and severally, to hold the United States harmless
on account of the reissue requested herein, 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/We 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 bonds.

Sign in ink in the presence of an authorized certifying officer.
(See the instructions for who must sign.)

(Signature)
(Signature)

(Signature)
(Signature)

(Title)

(Title)

(Number and Street or Rural Route)

(Number and Street or Rural Route)

(City)

(State)

(ZIP)

(City)

(State)

(Social Security Number)

(Social Security Number)

(Email Address)

(Email Address)

(Daytime Telephone Number)

(ZIP)

(Daytime Telephone Number)

The certification portion must be completed.
I CERTIFY that

I CERTIFY that

whose identity is known or was proven to me, personally

whose identity is known or was proven to me, personally

appeared before me this

day of

,

appeared before me this

day of

,

(Month)

, at
(Year)

(Month)

,
(City)

, at

(State)

(Year)

and signed this form.

(OFFICIAL STAMP
OR SEAL)

,
(City)

(State)

and signed this form.

(Signature of certifying officer)

(OFFICIAL STAMP
OR SEAL)

(Signature of certifying officer)

(Title of certifying officer)

(Title of certifying officer)

(Address)

(Address)

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PD F 4000

Reserved for Identification Notations
Customer Account Number
and Date Established: _________________________________

Customer Account Number
and Date Established: _________________________________

Identified by: _________________________________________

Identified by: _________________________________________

Documents – Descriptions: ____________________________

Documents – Descriptions: ____________________________

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. You must place an adequate notation in the area reserved for identification
notations in Part C 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, if you are an
officer or employee of an organization, 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.

FOR FEDERAL RESERVE BANK USE ONLY
This transaction was a reportable event.
$

was reported under

for
(Social Security Number)

.
(Year)

This transaction was not a reportable event. No interest was reported.

TAX LIABILITY: If the name of a living owner or principal coowner of the bonds is eliminated from the registration, the owner or
principal coowner must include the interest earned and previously unreported on the bonds to the date of the transaction on his or her
Federal income tax return for the year of the reissue. (Both registrants are considered to be coowners when bonds are registered in the
form: "A" or "B.") The principal coowner is the coowner who (1) purchased the bonds with his or her own funds, or (2) received them
as a gift, inheritance, or legacy, or as a result of judicial proceedings, and had them reissued in coownership form, provided he or she
has received no contribution in money or money's worth for designating the other coowner on the bonds. If the reissue is a reportable
event, the interest earned on the bonds to the date of the reissue will be reported to the Internal Revenue Service (IRS) by a Federal
Reserve Bank or Branch or the Bureau of the Public Debt under the Tax Equity and Fiscal Responsibility Act of 1982. THE
OBLIGATION TO REPORT THE INTEREST CANNOT BE TRANSFERRED TO SOMEONE ELSE THROUGH A REISSUE
TRANSACTION. If you have any questions concerning the tax consequences, consult the IRS, or write to the Commissioner of Internal
Revenue, Washington, DC 20224. Unless we are otherwise informed, the first-named coowner will be considered the principal
coowner for the purpose of this transaction.

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PD F 4000

INSTRUCTIONS

USE OF FORM – Complete this form to reissue paper (definitive) Series EE, E, HH, H, and I United States Savings Bonds,
Retirement Plan Bonds, and Individual Retirement Bonds. A separate Part A must be used for each new form of registration. If
more space is needed for any item, use a plain sheet of paper or make photocopies, as necessary, and attach to the form. To
request payment, sign the backs of the bonds instead of completing this form.
INCOMPETENT OR MINOR – A minor of sufficient age and competency to sign the request and to understand the nature of the
transaction may request reissue of the bonds. A minor under legal guardianship may not request reissue. An incompetent owner,
coowner or beneficiary may not request reissue.

PART A – NEW BOND REGISTRATION
1. Describe the bonds to be reissued.
2. Mark the box “In full” if the person listed in Item 3 is to receive the entire value of the bond(s) described in Item 1; or if the
person listed in Item 3 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.
3. Provide the following information:
a. The appropriate taxpayer identification number (social security number or employer identification number).
If the new bonds are to be inscribed in the name of . . .

Provide this . . .

One person as owner, with or without a beneficiary
Two persons as coowners

The social security number of the owner
The social security number of the first-named coowner

A guardian, custodian, or similar representative of the estate of
a minor, incompetent, or other ward

The social security number of the minor, incompetent, or
other ward

Other fiduciary registration (trustee, administrator of decedent’s
estate, etc.)

The social security number of the grantor of the trust or
decedent or an employer identification number assigned to
the fiduciary estate.

b. The new registration.
c. Mailing information. This address will be shown on the new bonds, unless alternate delivery instructions are
provided in Item 4.
d. To add a coowner or beneficiary, mark the appropriate box and insert his/her name. If a name is shown
and no box is marked, coownership will be assumed.
4. To have the bonds mailed to an address other than the address shown in Item 3, provide the name and address of
the person or institution receiving them. This address will be shown on the new bonds.

PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
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 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 correct address shown in “Where to
send” in the Instructions.

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PD F 4000

PART B – REASON FOR REISSUE
Describe the reason for the reissue. The chart below shows common reasons for reissue. These may not be authorized
for all Series. Complete guidelines for authorized reissue transactions may be found in the regulations, in the following
Department Circulars: DC 530 (Series E/H), DC 3-80 (Series EE/HH), DC 2-98 (Series I), DC 1-75 (IRB), and DC 1-63 (RPB).
Bonds may be reissued to…
Add a new coowner or beneficiary
to a bond in sole owner
registration.
Change the present beneficiary to
coowner.
Remove the name of a living
beneficiary.
Remove the name(s) of any
deceased registrant(s).

The form must be signed by…
The owner.

Additional Information
The original owner must be the first-named
coowner.

The owner.

Show that a change of name
occurred.

The person whose name has
changed.

Correct an error in registration.

The purchaser.

The beneficiary may only be shown as secondnamed coowner.
The owner may add a different person as
coowner or beneficiary.
The surviving registrant must be shown as the
owner or first-named coowner in the registration
of the new bonds. If more than one registration is
requested, a separate Part A must be completed
for each different registration. Submit certified
copies of the death certificates for all deceased
registrants except beneficiaries on Series EE,
HH, or I bonds.
Explain exactly how the change of name was
authorized (marriage, divorce, court order,
naturalization, etc.). Evidence may be required.
Provide the answers to the questions shown.

Substitute the name of the fiduciary
who has succeeded the fiduciary
named in the registration of the
bonds.

The owner (and the beneficiary if
Series E or Series H bonds).
The surviving registrant.

If the purchaser and the person
whose funds were used to purchase
the bonds are different persons, both
must sign.
The successor in his/her fiduciary
capacity.

Show the name of the executor or
administrator of a deceased
owner’s estate.

The fiduciary in his/her fiduciary
capacity.

Show the name of the guardian,
conservator, or similar
representative of the estate of a
minor or incompetent owner.
Change ownership due to divorce,
legal separation, or annulment.

The fiduciary in his/her fiduciary
capacity.

The owner or both coowners (or
their representatives).

Submit proof of the succession to the position,
such as a certified copy of the letters of
appointment or, in the case of a trustee, a copy of
the trust instrument and proof of the death or
resignation of the original trustee.
Submit a certified copy of the letters of
appointment, dated within one year of submission
and certified copies of the death certificates for all
deceased registrants.
Submit a certified copy of the letters of
appointment, dated within one year of
submission.
See the Tax Liability statement on this form. The
name of another person may be added as
coowner or beneficiary.

For bonds in coownership form, a
request solely to eliminate the name
of one coowner may be signed by
that coowner only.

Remove a living owner/coowner
and reissue in a form authorized
under the regulations.

For Series E or H bonds, the current
beneficiary must consent to the
reissue if his/her name is also being
removed.
The owner/coowner being removed.

Remaining registrant must be named first in the
registration.

For Series E or H bonds, the current
beneficiary must consent to the
reissue if his/her name is also being
removed.

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PD F 4000

PART C – SIGNATURES AND CERTIFICATIONS
SIGNATURES - Sign the form in ink, in the presence of an authorized certifying officer. The form must be signed as indicated in
Part B of the instructions. If the request is on behalf of a corporate fiduciary, the name of the corporation must be given, followed
by the signature and title of an authorized officer. If there are two or more fiduciaries, all must join in the request unless by
express statute, decree of court, or the terms of the instrument under which the fiduciaries are acting, one or more of them may
properly execute the request.
If an owner/coowner's name has been changed by marriage, divorce, court order, naturalization, or otherwise, he/she must sign
the form as follows: " (PRESENT LEGAL NAME) ", changed by (specify manner in which change occurred) from
" (NAME AS ON BONDS)." To support a change of name, other than by marriage, a complete statement should follow the
signature to show exactly how the change of name was authorized. Evidence may be required.
CERTIFICATION – Each person whose signature is required must appear before and establish identification to the satisfaction of
an authorized certifying officer. If a minor owner or coowner signs the request, the officer must be satisfied that the minor is of
sufficient competency to understand the nature of the transaction. The signatures to the form must be signed 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 financial institutions, including credit unions.

ADDITIONAL REQUIREMENTS FOR SERIES HH/H BONDS:
•

•

Under the Interest Dividend Tax Compliance Act of 1983 as implemented by Internal Revenue Service regulations,
the new owner or first-named coowner must complete IRS Form W-9 to certify that the social security number
furnished is correct, to indicate whether or not he/she is subject to backup withholding under the provision of Section
3406(a)(1)(C) of the Internal Revenue Code, and to verify that he/she is a United States person (including a U.S.
resident alien). Forms W-9 are available at financial institutions in the United States and Internal Revenue Offices.
These forms can also be found on the IRS website at the address www.irs.gov.
The furnishing of Direct Deposit information is a condition of reissue of Series HH bonds bearing issue dates of
October 1989 and thereafter. A Direct Deposit form, PD F 5396 or SF 1199A, must be completed for Series HH
bonds dated October 1989 and thereafter which are submitted for reissue. The Direct Deposit form must be
completed by the new owner or coowner providing the appropriate information for direct deposit of the semi-annual
interest payments. Forms SF 1199A are available at financial institutions in the United States. PD F 5396 is
available for download on the Internet using the "forms" link at the address www.treasurydirect.gov. The financial
institution designated to receive the payment can assist in the completion of the Direct Deposit form.

ADDITIONAL EVIDENCE – 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.
RETURN OF EVIDENCE - If the evidence submitted with this form is to be returned, provide a written request when the
evidence is submitted.
WHERE TO SEND – Unless otherwise instructed, the PD F 4000 and the bonds, as well as any other appropriate forms and
evidence, must be sent to one of the Treasury Retail Securities Sites shown below:
Treasury Retail Securities Site
PO Box 214
Minneapolis, MN 55480-0214
1-800-553-2663

Treasury Retail Securities Site
PO Box 299
Pittsburgh, PA 15230-0299
1-800-245-2804

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PD F 4000