Form PD F 5396 PD F 5396 Direct Deposit Sign Up Form

For official use only:
Customer Name

Customer No.

PD F 5396 E
Department of the Treasury
Bureau of the Public Debt
(Revised April 2008)

OMB No. 1535-0128

Direct Deposit Sign-Up Form
Check one:

Interest payments

Redemption payment

Check this box if the address furnished below should not be used to update HH/H accounts.
Please Print:
Name (or names, if joint account)
Address

(Work)

Telephone No. (Home)
Social Security No.

–

–

–

OR Employer Identification No.

Enter the following information OR attach a voided check: *
Depositor’s Account No.

Type of Account
Checking

Bank Routing No.

–

–

*

Phone No.

(

Financial Institution Name

Savings

)

–

If you want payments deposited at a credit union, DO NOT ATTACH A VOIDED CHECK. Ask the credit union to tell you the
correct routing number to use on this form.

For a joint account, only the person whose taxpayer identification number is shown should sign the form.
Under penalty of perjury, I certify that:
1. The taxpayer identification number shown on this form is my correct taxpayer identification number (or I am waiting for a number
to be issued to me), and
2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the
Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends,
or (c) I have been notified by the Internal Revenue Service that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien).
(Instructions - You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return.)
(Signature)

(Date)

Instructions:
Complete and sign this form to request the direct deposit of Series HH/H bond interest payments or a savings bond redemption payment.
Unless otherwise notified, the address and direct deposit information furnished will be updated on all HH/H accounts under the
taxpayer identification number provided.
WHERE TO SEND – Unless otherwise instructed, send the completed and signed form and, if applicable, the properly signed and certified
bond(s), as well as any other appropriate forms and evidence, to one of the Treasury Retail Securities Sites shown below:
Treasury Retail Securities Site
PO Box 299
Pittsburgh, PA 15230-0299

Treasury Retail Securities Site
PO Box 214
Minneapolis, MN 55480-0214

1-800-245-2804

1-800-553-2663

NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
The collection of the information you are requested to provide on this form is authorized by 31 U.S.C. CH. 31 relating to the public debt of the United States. The furnishing of
a social security number, if requested, is also required by Section 6109 of the Internal Revenue Code (26 U.S.C. 6109).
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, identify owners
and their accounts, and provide reports to the Internal Revenue Service. 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 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. DO NOT SEND completed form to the above address; send to the correct address shown in the instructions.