Form BEP 5283 BEP 5283 Owner's Affidavit of Partial Destruction of Mutilated Cu

FORM 5283
REV. 10-07
PREVIOUS EDITION OBSOLETE

OMB NO: 1520-0001

BEP

DEPARTMENT OF THE TREASURY

OWNER'S AFFIDAVIT OF PARTIAL DESTRUCTION
OF MUTILATED CURRENCY
IMPORTANT: Any person who makes a claim or statement on this form which he knows to be
false or fraudulent may be fined $10,000 or imprisoned for 5 years or both. Please read
instructions on back before completing this form.
TO DEPARTMENT OF THE TREASURY:
I,

, being duly sworn according to law, declare:

(Please print name of owner)

(1) That I reside at

(Number and street or rural route)

and have so resided for

(City)

(State)

years.

(2) That I am the owner of United States currency in the amount of $
(3) That said currency was partially destroyed on the

day of

, 20

in the following manner (Give complete details):

(If space is insufficient, continue onto a separate sheet. Initial and date the sheet. Attach it firmly,
and refer above to the attachment.)

(4) That the recovered portions of said currency have been or are herewith surrendered for redemption pursuant to the
regulations governing relief, and that any missing portions of such currency, to the best of my knowledge and belief, were
totally destroyed as described above.
(Signature of owner)

Subscribed and sworn to before me this
at

day of

, county of

, 20
, State of

by the above-named person, whose identity is well known or proved to me.

[SEAL]
My commission expires

(Signature of notary public or similar officer)

(Official designation)

,

The following statement is now required by the Office of Management and Budget to be printed on all information collections (forms):
The estimated average burden associated with this collection of information is one hour per respondent or record keeper depending on individual
circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Bureau
of Engraving and Printing, Mutilated Currency Division, 14th and C Streets, S.W., Washington, D. C. 20228, and to the Offices of Information and
Regulatory Affairs, and the Office of Management and Budget, Paperwork Reduction Project (1520-0001), Washington, D. C. 20503.

INSTRUCTIONS - PLEASE FOLLOW CAREFULLY
1. COMPLETION OF FORM. Fill in all blanks with the information called for. Statements
explaining the cause and manner of destruction must prove to the satisfaction of the Department of
the Treasury that the missing portions were so completely destroyed that they could never become
the basis of a claim against the United States.
2. EXECUTION OF AFFIDAVIT. The completed form must be signed and sworn to in the
presence of a notary public or similar officer authorized by law to administer oaths. Be sure he fully
completes and signs the form provided for his use.
3. FORWARDING INSTRUCTIONS. The affidavit, and recovered portions of currency if not
previously submitted, must be sent to the Treasury Department, Bureau of Engraving and Printing,
MCD/BEPA Room 344 P.O. Box 37048 Washington, D.C. 20013. For the protection of owners,
currency should always be sent by registered mail unless covered by insurance or presented in
person.

PRIVACY ACT INFORMATION
General
The information called for on this form is needed in order for the Treasury Department to
determine legal ownership of the damaged currency in question or, in some cases, to determine
whether the missing portions of currency described in the claim have been totally destroyed.
While responses to this request are voluntary, failure to furnish all of or, part of the requested
information may result in a denial of your claim.
Information relating to claims of $5000 or more will be provided to the Internal Revenue Service.
The Treasury Department is authorized to exchange mutilated currency pursuant to 31 U.S.C.
773a and the regulations thereunder, 31 C.F.R. Part 100.