On-line PD F 5263 Order for U.S. Savings Bonds (output)

PD F 5263
Department of the Treasury
Bureau of the Public Debt
(Revised June 2010)

ORDER FOR SERIES EE U.S. SAVINGS BONDS

Owner Name:

John Doe

Owner SSN:

654789123

Mail to:

John Doe

Address:

1234 Anystreet Ave

City/State/ZIP:

Anycity

CoOwner/Ben Code:

C

Coowner/Beneficiary:

Jane Doe

Denomination

Quantity Issue Price

PA

0

X $50

$0.00

$75

0

X $75

$0.00

$100

0

X $100

$0.00

$200

0

X $200

$0.00

$500

0

X $500

$0.00

$1000

0

X $1000

$0.00

$5000

0

X $5000

$0.00

$10000

1

X $10000

$5,000.00

TOTAL PRICE:

$5,000.00

8642

15201

Sub-Total

$50

PURCHASER INFORMATION:
Name:
Address:
City/State/ZIP:
Phone#:

OMB No. 1535-0084

John Doe
1234 Anystreet Ave
Anycity
PA,
15201
1-234-567-8901

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8642

PD F 5374
Department of the Treasury
Bureau of the Public Debt
(Revised June 2010)

ORDER FOR SERIES I U.S. SAVINGS BONDS

Owner Name:

John Doe

Owner SSN:

654789123

Mail to:

John Doe

Address:

1234 Anystreet Ave

City/State/ZIP:

Anycity

CoOwner/Ben Code:

C

Coowner/Beneficiary:

Jane Doe

Denomination

PA

Quantity Issue Price

Sub-Total

$50

6

X $50

$300.00

$75

5

X $75

$375.00

$100

4

X $100

$400.00

$200

3

X $200

$600.00

$500

2

X $500

$1,000.00

$1000

1

X $1000

$1,000.00

$5000

0

X $5000

$0.00

TOTAL PRICE:

$3,675.00

PURCHASER INFORMATION:
Name:
Address:
City/State/ZIP:
Phone#:

1357

OMB No. 1535-0084

John Doe
1234 Anystreet Ave
Anycity
PA,
15201
1-234-567-8901

15201

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1357

CUSTOMER COPY
Please keep for your records

U.S. Savings Bond Order Summary
BOND REGISTRATION

John Doe OR Jane Doe
1234 Anystreet Ave
Anycity, PA 15201

PHONE NUMBER

1-234-567-8901

DATE
8/2/2010

DESCRIPTION

DENOMINATION

QUANTITY

AMOUNT

Series I Bonds

$50
$75
$100
$200
$500
$1000

6
5
4
3
2
1

$3,675.00

Series EE Bonds

$10000

1

$5,000.00

22

$8,675.00

TOTAL

To complete your order, mail the following:
- Check in the amount of $8,675.00, payable to Federal Reserve Bank of Cleveland
- Order for Series I U.S. Savings Bonds
- Order for Series EE U.S. Savings Bonds
Mail to:
FEDERAL RESERVE BANK OF CLEVELAND
PITTSBURGH BRANCH
P.O. BOX 100
PITTSBURGH, PA 15230