Pd F 5235 Report Of Non-receipt, Loss, Etc. Of Fiscal Agency Check

RESET
For official use only:
Customer Name

Customer No.

PD F 5235 E
Department of the Treasury
Bureau of the Public Debt
(Revised February 2010)

REPORT OF NONRECEIPT, LOSS, THEFT, OR DESTRUCTION OF
FISCAL AGENCY CHECK AND APPLICATION FOR REPLACEMENT

OMB No. 1535-0069
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

1.

RETURN THIS FORM TO:
Bureau of the Public Debt, PO Box 7012, Parkersburg, WV 26106-7012. For E/EE/I savings bonds.
Bureau of the Public Debt, PO Box 2186, Parkersburg, WV 26106-2186. For HH/H savings bonds.
Bureau of the Public Debt, PO Box 426, Parkersburg, WV 26106-0426. For Treasury Bills, Notes, Bonds, and TIPS.
Federal Reserve Bank of

2.

.

REQUESTED ACTION:
I/We hereby report the nonreceipt, loss, theft, or destruction of a fiscal agency check issued in connection with United States

securities and request issuance of a replacement payment. I/We
3.

. . . that a stop-payment order be
placed against the check described
in Item 4.

have requested . . .
hereby request . . .

SECURITY DESCRIPTION. The check was issued in connection with:
a. U.S. Savings or Retirement Bonds:
Series E

Series EE

Retirement Plan Bonds

Savings Notes

Series H

Series HH

Series I

Individual Retirement Bonds

b. U.S. Treasury Marketable Securities:
Legacy Treasury Direct®

Bill

Note

Bond

TIPS

(Replacement payment may be by direct deposit.)

(Term)

Legacy Treasury Direct Account Number
Paper Securities:

Coupon Note

Coupon Bond

Registered Note

Registered Bond

Other
c. Additional identifying information (loan title, pieces, face amount, form(s) of registration):

4.

CHECK DESCRIPTION. The check was issued in connection with:
a. Type of payment:
Principal

Interest

Discount or Refund

Coupons

Other
b. Date of payment:
c. If the payment was made in connection with securities or coupon(s) presented for payment, indicate where presented:
Federal Reserve Bank of
Bureau of the Public Debt, Parkersburg, WV
d. Social Security Number of first-named payee:
e. Amount of check:
f. Serial number of check (if known):
g. Name(s) inscribed on the check:

Other

h. The check was:
Never received

Received then lost

Received then stolen

i. If lost, stolen, or destroyed, was the check endorsed?

Yes

No

Received then destroyed

If Yes, show the exact form of endorsement:

j. Tell us the circumstances surrounding the loss, theft, or destruction:

k.

5.

I hereby warrant that all other payees named on the check(s) did not have access to the check. Therefore, I request waiver
of the requirement for all other payees to execute the application and agreement.

INDEMNIFICATION AGREEMENT AND SIGNATURE(S):

You must wait until you are in the presence of a certifying individual to sign this form.
In consideration of the issuance of a replacement payment, I/we agree that if the missing check ever comes into my/our possession or
under my/our control, I/we will return it to the Bureau of the Public Debt or a Federal Reserve Bank. Further, I/we indemnify and hold
harmless the United States of America, the Department of the Treasury, and the payor Federal Reserve Bank, against all claims or
demands and all loss, damage, and expense, including legal fees and expenses, that may be incurred from paying the check reported
lost or refusing to pay the check if presented.

Sign here:

Sign here:
Payee's Signature

Second Payee's Signature

Number and Street or Rural Route

Number and Street or Rural Route

City

State

ZIP Code

City

State

Daytime Telephone Number

Daytime Telephone Number

E-Mail Address

E-Mail Address

ZIP Code

Instructions to Certifying Individual:
1. Name of person(s) who appeared and date of appearance MUST be completed. NOTE: For a second person, use Page 3.
2. Medallion stamps require an original signature.
3. Person(s) must sign in your presence.

I certify that

, whose identity is known or
Name of Person Who Appeared

proven to me, personally appeared before me this

day of

,
Month/Year

, and signed this form.

at
City, State
ACCEPTABLE CERTIFICATIONS:
Financial Institution’s Official Seal or Stamp (such as Corporate
Seal, Signature Guaranteed Stamp, or Medallion Stamp).
Brokers must use a Medallion Stamp.

Signature and Title of Certifying Individual

Name of Financial Institution
Address

City, State, ZIP Code
Telephone

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PD F 5235 E

I certify that

, whose identity is known or
Name of Person Who Appeared

proven to me, personally appeared before me this

day of

,
Month/Year

at

, and signed this form.
City, State

ACCEPTABLE CERTIFICATIONS:
Financial Institution’s Official Seal or Stamp (such as Corporate
Seal, Signature Guaranteed Stamp, or Medallion Stamp).
Brokers must use a Medallion Stamp.

Signature and Title of Certifying Individual

Name of Financial Institution
Address

City, State, ZIP Code
Telephone

INSTRUCTIONS
USE OF FORM – Payee(s) can use this form to report the nonreceipt, loss, theft, or destruction of fiscal agency checks
and to apply for a replacement payment. The form provides the necessary information to place a hold on the payment of
the missing check and constitutes an application for the issuance of a replacement payment. Before a replacement
payment can be issued, additional evidence and a bond of indemnity may be required.
COMPLETION OF FORM – Print clearly in ink or type all information requested. If more space is needed for any item, use
a plain sheet of paper and attach it to this form.
ITEM 1.

This item is completed by the servicing office, advising you where to return the completed form.

ITEM 2.

Mark the appropriate box regarding stop-payment.

ITEM 3.

Mark the appropriate box(es) to show for what type(s) of security(ies) the check was issued. Provide any
additional identifying information in Item 3c.

ITEM 4.

Furnish all requested information:
a. Show the type of payment for which the check was issued.
b. Furnish the date of payment.
c. Indicate where the securities or coupons were presented for payment.
d. Furnish the first-named payee's Social Security Number.
e. Show the amount of the check.
f. Provide the serial number of the check, if known.
g. Provide the names that were inscribed on the check.
h. Indicate whether the check was never received, or received and then lost, stolen, or destroyed.
i. Indicate whether the check was endorsed and, if so, provide the exact form of endorsement.
j. If the check was lost, stolen, or destroyed after receipt, furnish the circumstances of the loss, theft, or
destruction.
k. Mark this box if the other payees named on the check did not have access to the check and you are
requesting a waiver of the requirement for all payees to join in executing the application and
agreement.

ITEM 5.

Sign the form in ink and provide your complete home address, daytime telephone number, and e-mail
address, if applicable. If there are two payees, both must sign unless Item 4k is marked. Each signature
must be certified (see "CERTIFICATION" section below).

CERTIFICATION – You must appear before and establish identification to the satisfaction of an authorized certifying
officer, and sign the form in the officer’s presence. The certifying officer must complete the certification forms provided and
affix the seal or stamp which is used when certifying requests for payment. Brokers must use a Medallion Stamp.
Authorized certifying officers are available at financial institutions, including credit unions, in the United States. For a
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PD F 5235 E

complete list of such officers, see Department of the Treasury Circular Nos. 300 and 530, current revisions, and Public
Debt Series Nos. 3-80 and 2-98.
WHERE TO SEND – Send the completed form to the address shown in Item 1. If no box is checked in Item 1, send the
form to the servicing office which sent it to you.

PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
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 Item 1.

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PD F 5235 E