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Customer Name
Customer No.
PD F 1455 E
Department of the Treasury
Bureau of the Public Debt
(Revised July 2011)
REQUEST BY FIDUCIARY FOR DISTRIBUTION OF
UNITED STATES TREASURY SECURITIES
OMB No. 1535-0012
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
One or more fiduciaries (individual or corporate) must use this form to establish entitlement and request distribution of United States
Treasury Securities and/or related payments to the person lawfully entitled due to termination of a trust, distribution of an estate,
attainment of majority, restoration to competency, or other reason.
PART A – REASON FOR DISTRIBUTION
I/We request distribution of the securities and/or related payments for the following reason:
Termination of trust
Distribution of an estate
Payment to the estate
Reissue to the estate
Distribution to person(s) entitled*
* If payment is requested by person(s) entitled, a PD F 1522 is required.
If reissue to add another person is requested by person(s) entitled, a PD F 4000 is required.
If reissue to a trust is requested, a PD F 1851 is required.
NOTE: Savings bonds within one month of final maturity cannot be reissued.
Attainment of majority
Restoration to competency
Other:
PART B – DISTRIBUTION OF SECURITIES AND PAYMENTS
I/We request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)
OR
(Social Security Number)
(Employer Identification Number)
(Address and Telephone Number)
2. Description of securities and/or related payments:
TITLE OF SECURITY
3. Extent of distribution:
ISSUE
DATE
FACE AMOUNT
IDENTIFYING NUMBER
In full
(Amount, Fractional Share, or Percentage)
REGISTRATION
PART B – DISTRIBUTION OF SECURITIES AND PAYMENTS (Continued)
I/We request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)
OR
(Social Security Number)
(Employer Identification Number)
(Address and Telephone Number)
2. Description of securities and/or related payments:
TITLE OF SECURITY
3. Extent of distribution:
ISSUE
DATE
FACE AMOUNT
IDENTIFYING NUMBER
REGISTRATION
In full
(Amount, Fractional Share, or Percentage)
I/We request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)
OR
(Social Security Number)
(Employer Identification Number)
(Address and Telephone Number)
2. Description of securities and/or related payments:
TITLE OF SECURITY
3. Extent of distribution:
ISSUE
DATE
FACE AMOUNT
IDENTIFYING NUMBER
REGISTRATION
In full
(Amount, Fractional Share, or Percentage)
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PD F 1455 E
PART C - SIGNATURES AND CERTIFICATIONS
I/We certify under penalty of perjury that the information provided herein is true and correct to the best of my/our knowledge
and belief, and agree to distribution of the securities as indicated in Part B. I/We bind ourselves, our heirs, legatees, successors
and assigns, jointly and severally, to hold the United States harmless on account of the transaction requested, and to indemnify
unconditionally and promptly repay the United States in the event of any loss which results from this request, including interest,
administrative costs, and penalties. I/We consent to the release of any information regarding this transaction, including information
contained in this form, to any party having an ownership or entitlement interest in the securities or payments.
You must wait until you are in the presence of a certifying officer to sign this form.
Sign Here:
(Signature)
(Applicant’s Title)
(Number and Street, Rural Route, or PO Box)
(City)
(Daytime Telephone Number)
(State)
(ZIP Code)
(E-Mail Address)
Instructions to Certifying Officer:
1. Name of person(s) who appeared and date of appearance MUST be completed.
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)
(Signature and Title of Certifying Officer)
(OFFICIAL STAMP
OR SEAL)
(Name of Financial Institution)
(Address)
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.
(City, State, ZIP Code)
(Telephone)
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PD F 1455 E
You must wait until you are in the presence of a certifying officer to sign this form.
Sign Here:
(Signature)
(Applicant’s Title)
(Number and Street, Rural Route, or PO Box)
(City)
(State)
(Daytime Telephone Number)
(ZIP Code)
(E-Mail Address)
Instructions to Certifying Officer:
1. Name of person(s) who appeared and date of appearance MUST be completed.
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)
(Signature and Title of Certifying Officer)
(OFFICIAL STAMP
OR SEAL)
(Name of Financial Institution)
(Address)
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.
(City, State, ZIP Code)
(Telephone)
INSTRUCTIONS
USE OF FORM – One or more fiduciaries (individual or corporate) must use this form to establish entitlement and request distribution of
United States Treasury Securities and/or related payments to the person lawfully entitled due to termination of a trust, distribution of an
estate, attainment of majority, restoration to competency, or other reason.
If more space is needed for any item, use a plain sheet of paper or make photocopies, as necessary, and attach to the form.
PART A – REASON FOR DISTRIBUTION
Mark a box to show the reason for the distribution. If you mark “Other,” describe the reason.
Submit a copy of all evidence that establishes your authority to request this transaction. For example, if you are the
administrator or executor of an estate, provide a certified copy of your letters of appointment, dated within one year of
submission. Submit certified copies of death certificates for all deceased registrants.
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PD F 1455 E
PART B – DISTRIBUTION OF SECURITIES AND PAYMENTS
Complete Items 1 through 3.
1.
Enter the name of only one distributee in each Part B, Item 1. (A separate Part B must be completed for each distributee.) Enter the
appropriate Social Security Number or Employer Identification Number.
2.
Describe only the securities and/or checks which the person shown in Item 1 is to receive, in whole or in part:
TITLE OF SECURITY – Identify each security by series, interest rate, type, CUSIP, call and maturity date, as appropriate.
If describing a check, insert the word “check.”
ISSUE DATE – Provide the issue date of each security or check.
FACE AMOUNT – Provide the face amount (par or denomination) of each security or check.
IDENTIFYING NUMBER (if applicable) – Provide the serial number of each security, the confirmation number, or the
check number.
REGISTRATION – Provide the registration of each security, check, or account; also provide the account number, if any.
EXAMPLES:
TITLE OF SECURITY
ISSUE
DATE
FACE AMOUNT
5/15/79
$5,000
Paper Marketable Security
9 1/8 % TREASURY BOND OF
2004-2009 MATURES 5/15/09
CUSIP 912810CG1
Electronic Marketable Security
CUSIP 912795QW4
Electronic Series I Savings Bond
SERIES I
Paper Series EE Savings Bond
SERIES EE
IDENTIFYING NUMBER
REGISTRATION
Serial #
2/5/04
$1,000
1/1/02
$100
7/99
$100
7/26/04
$351.02
JOHN DOE AND JANE DOE
SSN 222-22-2222
123
ACCT # 4800-123-1234
JOHN DOE
SSN 222-22-2222
Confirmation #
12345
Serial #
C-123,456,789-EE
ACCT # N-111-111-111
JOHN DOE
SSN 222-22-2222
JOHN DOE
OR JANE DOE
Check #
Check
CHECK
502123456
JOHN DOE
If unsure what to provide in each of the areas, furnish all identifying information in the space for REGISTRATION.
3.
Mark the box “In full” if the person listed in Item 1 is to receive the entire value of the securities and/or checks described in Item 2. If
the person listed in Item 1 is not to receive the entire value, mark the second box and provide the appropriate amount, fractional
share, or percentage he/she is to receive.
In most cases, we will need additional forms and/or information from the distributee. If so, we may contact the distributee directly. If the
transaction can be processed without additional forms or information from the distributee, we will send the securities and/or payments
directly to the distributee.
Note: If the distributee wants payment of eligible paper securities and the securities are:
Savings bonds or notes, he/she must complete the request on the reverse of the bond.
Marketable securities, the fiduciary must complete the assignment on the reverse of the security. The distributee must
complete IRS Form W-9.
Any interest that is or becomes due on securities belonging to the estate of the decedent will be paid to the person to whom the securities
are distributed, unless otherwise requested.
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PD F 1455 E
PART C – SIGNATURES AND CERTIFICATIONS
SIGNATURES – The form must be signed in ink. Sign the form in your fiduciary capacity. If the request is on behalf of a corporate
fiduciary, the name of the corporation must be given, followed by the signature and title of an authorized officer. If there are two or more
fiduciaries, all must join in the request unless by express statute, decree of court, or the terms of the instrument under which the
fiduciaries are acting, one or more of them may properly execute the request.
CERTIFICATION – Each person whose signature is required must appear before and establish identification to the satisfaction of an
authorized certifying officer. The signatures to the form must be signed in the officer’s presence. The certifying officer must affix the seal
or stamp which is used when certifying requests for payment. Authorized certifying officers are available at most financial institutions,
including credit unions.
Sample certification for a financial institution:
Acceptable certification for a brokerage:
SIGNATURE GUARANTEED
SIGNATURE GUARANTEED
ABC National Bank
MEDALLION GUARANTEED
Hillview Branch
Generic Brokerage
Authorized Signature
Authorized Signature
XXXXXXXX
SECURITIES TRANSFER AGENTS MEDALLION PROGRAM
[Bar Code]
ADDITIONAL EVIDENCE – The Commissioner of the Public Debt, as designee of the Secretary of the Treasury, reserves the right in any
particular case to require the submission of additional evidence.
RETURN OF EVIDENCE – If you want the evidence submitted with this form returned to you, please provide a written request when you
submit the form and evidence.
WHERE TO SEND – Unless otherwise instructed in accompanying correspondence, send to the Department of the Treasury, Bureau of
the Public Debt, using the appropriate address below:
Series H or Series HH savings bonds – PO Box 2186, Parkersburg, WV 26106-2186
Definitive (paper) savings bonds – PO Box 7012, Parkersburg, WV 26106-7012
Book-entry savings bonds and marketable securities held in TreasuryDirect – PO Box 7015, Parkersburg, WV 26106-7015
Marketable securities held in Legacy Treasury Direct – PO Box 426, Parkersburg, WV 26106-0426
Definitive (paper) marketable securities – PO Box 426, Parkersburg, WV 26106-0426
NOTICE UNDER PRIVACY ACT AND PAPERWORK REDUCTION ACT
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 30 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 this
address; send to the appropriate address shown in "WHERE TO SEND" in the Instructions.
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PD F 1455 E
| File Type | application/pdf |
| File Title | Microsoft Word - PDF1455.dot |
| Author | rlewis |
| File Modified | 2011-07-20 |
| File Created | 2011-07-19 |