PD F 5374 Series I Order For U.S. Savings Bonds

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PD F 5374 E
Department of the Treasury
Bureau of the Public Debt
(Revised July 2001)

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SERIES I

OMB No. 1535-0084

ORDER FOR U.S. SAVINGS BONDS

Previous Editions Usable

PLEASE FOLLOW THE INSTRUCTIONS ON THE BACK. PRINT IN CAPITAL LETTERS. SCANNABLE FORM — DO NOT WRITE OUTSIDE BOXES.

1. FULL NAME OF OWNER OR FIRST-NAMED COOWNER
Name
Social Security Number
2. NAME OF PERSON TO RECEIVE BONDS IF OTHER THAN THE OWNER OR FIRST-NAMED COOWNER ABOVE
Mail
to:
3. ADDRESS WHERE BONDS ARE TO BE MAILED

(NUMBER AND STREET, RURAL ROUTE, OR POST OFFICE BOX)

(CITY OR TOWN)

(STATE)

4. COOWNER OR BENEFICIARY (Optional) The following person is to be named as

(ZIP CODE)

beneficiary:

coowner

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Name
(Coownership will be assumed if neither or both blocks are checked.)
5. BONDS ORDERED

Quantity

Denom.

FOR AGENT USE ONLY

Total Issue Price

Issue Price

$

50

X$

50.00

=$

,

.00

$

75

X$

75.00

=$

,

.00

$

100

X$

100.00

=$

,

.00

$

200

X$

200.00

=$

,

.00

$

500

X$

500.00

=$

,

.00

$

1,000

X $ 1,000.00

=$

,

.00

$

5,000

X $ 5,000.00

=$

,

.00

$

10,000

X $ 10,000.00

=$

,

.00

$

,

.00

TOTAL ISSUE PRICE OF PURCHASE

AFFIXED AGENT STAMP CERTIFIES THAT
TOTAL AMOUNT OF PURCHASE IS CORRECT

6. DATE PURCHASE ORDER AND PAYMENT PRESENTED TO AGENT
(MO.)

(DAY)

(YR.)

7. SIGNATURE
IF YOU NEED A GIFT CERTIFICATE, PLEASE
ASK THE PERSON ACCEPTING THIS FORM TO
PROVIDE ONE TO YOU.
PURCHASER’S SIGNATURE

(
PURCHASER’S NAME, IF OTHER THAN OWNER OR FIRST-NAMED COOWNER (Please print)

STREET ADDRESS (If not shown above)

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5374

03 99

)
DAYTIME TELEPHONE NUMBER

CITY

STATE

ZIP CODE

SEE INSTRUCTIONS FOR PRlVACY ACT AND PAPERWORK REDUCTION ACT NOTICE

FRB COPY

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INSTRUCTIONS FOR COMPLETING THE PURCHASE ORDER
1.

FULL NAME OF OWNER OR FIRST-NAMED COOWNER. Clearly PRINT in capital letters the full name and social security account
number of the owner or first-named coowner. Initials should not be provided for both first and middle names unless they are the owner’s
legal given name. A social security account number must be provided. If this is a gift bond purchase, use the owner’s name and social
security account number if available. If the owner’s social security account number is unavailable, use the purchaser’s number; use of the
purchaser’s number does not confer rights to the bond or require interest reporting. See example below.

J O

H N

T

Social Security Number

1

Name

S M

2 3

I

T

4 5

H

6 7 8 9

Bonds may be registered as follows:
(a) Individuals in their own right—The bonds may be issued in the names of individuals (whether adults or minors) in
single ownership, coownership, or beneficiary (POD) forms of registration.
(b) Others—Bonds are also available in other forms of registration. Trust forms of registration must be submitted on Form PD F 5374-1.
2.

NAME OF PERSON TO RECEIVE BONDS IF OTHER THAN OWNER OR FIRST-NAMED COOWNER ABOVE. After “Mail to:” print
the name to whom the bonds are to be mailed if different from the owner or first-named coowner shown in 1 above. If the same as in
1 above, leave blank.
NOTE: This information will appear on the bond, but does not establish any ownership rights.

3.

ADDRESS WHERE BONDS ARE TO BE MAILED. In all cases, print the address where the bonds are to be mailed.
NOTE: This information will appear on the bond.

4.

COOWNER OR BENEFICIARY (Optional). If you wish to name a coowner or beneficiary on the bonds, check the appropriate box to
indicate the form of registration desired and print the person’s full name. Coownership will be assumed if neither or both boxes are
checked.
If you name a coowner: The bonds may be cashed by either coowner. The name of a living coowner cannot be eliminated unless at
least one of the coowners is a party to a divorce or an annulment.
If you name a beneficiary: The bonds may not be cashed by the beneficiary during the lifetime of the owner. The name of a
beneficiary can be eliminated without the beneficiary’s consent.

5.

BONDS ORDERED. Indicate next to the appropriate denomination the number of bonds being purchased; the total price
involved for each denomination (no. of bonds X issue price); and the total amount of purchase. If you fail to indicate the
denomination preferred, the fewest number of bonds which equal the total amount of purchase will be issued.

6.

DATE PURCHASE ORDER AND PAYMENT PRESENTED TO AGENT. Indicate the date on which the purchase order and
payment is presented (received) and accepted by the bank or other financial institution authorized to act as an agent of
the Treasury Department.

7.

SIGNATURE. Please sign this purchase order. Print your name and address if they don’t appear in the registration of the bonds as
shown in Sections 1 and 3. In order to promptly resolve any problems connected with this purchase order, also provide a telephone
number where you ordinarily may be reached Monday through Friday, from 9 a.m. to 5 p.m.

NOTE: Upon completion, submit purchase order and total amount of purchase to a financial institution authorized to sell U.S. Savings
Bonds. ALLOW ABOUT THREE WEEKS FOR PROCESSING.
NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
The collection of the information you are requested to provide on this form, including the furnishing of a social security number, is authorized by 31 U.S.C. Ch. 31 relating to the
public debt of the United States.
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 and identify owners.
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 05 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; instead, send to a financial institution authorized to sell U.S. Savings Bonds.