Form PD F 4239 PD F 4239 Request By Owner or Person Entitled to Payment or Reissu

RESET
For BPD use only:
Customer Name

Customer No.

PD F 4239 E
Department of the Treasury
Bureau of the Public Debt
(Revised September 2010)

OMB No. 1535-0063

REQUEST BY OWNER OR PERSON ENTITLED TO PAYMENT
OR REISSUE OF UNITED STATES SAVINGS BONDS/NOTES DEPOSITED IN
SAFEKEEPING WHEN ORIGINAL CUSTODY RECEIPTS ARE NOT AVAILABLE

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

To: BUREAU OF THE PUBLIC DEBT, PO Box 7012, Parkersburg, WV 26106-7012.

1. I

,

,

(Name)

(Social Security Number)

certify that United States Savings Bonds, numbers
,

were held in safekeeping at:

Office of the Treasurer of the United States,
Federal Reserve Bank of

and that I am the person lawfully entitled to claim the bonds as:
owner
coowner
beneficiary
legal representative of
person entitled to the estate of
other (explain)
and that the original custody receipts were mislaid, lost, or stolen and, after a diligent search, have not been found.
I agree to return the original receipts to Public Debt for cancellation if they are ever located.
2. I request:

payment of the current redemption value by check
payment of the current redemption value by direct deposit
*new bonds in the same form of registration as the originals
*new bonds in the following form of registration

* Series EE and Series I savings bonds
within one month of final maturity
cannot be reissued.

New Registration:

Social Security Number of owner or first-named coowner:

(First name)

(Middle name or initial)

(Number and Street, Rural Route and Box Number, or P.O. Box)

(Last name)

(City)

(State)

(ZIP Code)

If a coowner or beneficiary is desired, complete the following line:
(First name)

(Middle name or initial)

(Last name)

as

coowner
beneficiary

3. Mail the bonds or check to:
(Name)

(Number and Street, Rural Route and Box Number, or P.O. Box)

(City)

(State)

(ZIP Code)

4. Signatures - You must wait until you are in the presence of a certifying officer to sign this form. (See the certification
sections on the next page.)
(Signature)

(Daytime Telephone No.)

(Signature)

(Daytime Telephone No.)

5. Certification.
Instructions to Certifying Individual:
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 was
(Name of Person Who Appeared)

proven to me, personally appeared before me this

day of

,
(Month / Year)

at

, and signed this form.
(City / State)

(Signature and Title of Certifying Individual)

(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)

(Notary certification is NOT acceptable.)

(Telephone)

I CERTIFY that

, whose identity is known or was
(Name of Person Who Appeared)

proven to me, personally appeared before me this

day of

,
(Month / Year)

at

, and signed this form.
(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)

(Notary certification is NOT acceptable.)

(Telephone)

2

PD F 4239 E

INSTRUCTIONS
USE OF FORM – When original safekeeping custody receipts are not available, use this form to request payment or reissue of United States
Savings Bonds/Notes deposited for safekeeping with the Office of the Treasurer of the United States or a Federal Reserve Bank.
(If safekeeping receipts are available, they must be submitted to the address shown on this form.)
WHO MAY COMPLETE THE FORM – The form must be completed by the owner, coowner, surviving beneficiary, legal representative of the
estate of a deceased or incompetent owner, or the person entitled to the estate of a deceased owner. If the original bonds are registered in
coownership form, this form must be signed by the coowner who deposited the bonds for safekeeping. Otherwise, the coowner's agreement or
evidence of his/her death is required.
EVIDENCE – The following evidence is required to support the request:
Request by:
Evidence Required
1. Surviving coowner or
A copy of the deceased registrant's death certificate, certified or sworn to by the State or local registrar,
beneficiary
under seal, to be a true and correct copy taken from the official records.
2. Legal representative of the
estate of a deceased or
incompetent owner

A court certificate or a certified copy of the representative's letters of appointment, under seal of the
court, showing that the appointment is still in full force and effect. If there is no legal representative in
the case of a deceased or incompetent owner or the decedent's estate has been fully administered and
closed, Public Debt must be so informed and further instructions will be provided.

COMPLETION OF FORM
 ITEM 1. Check the appropriate boxes to indicate where the bonds were held and your entitlement to them. List the bonds by serial number.
 ITEM 2. Mark the appropriate box to indicate whether payment or reissue is desired. For payment by direct deposit, also see Item 3 below.
If new bonds are desired and the bonds are to be reissued in a different form of registration than the originals, show the new
registration. If two persons are named on a bond and one dies, the surviving person may designate a new coowner or beneficiary,
provided the surviving person furnishes proof of the death of the deceased (see "EVIDENCE" above). If a security has matured or
will reach maturity before a reissue can be processed, payment will be issued. All Savings Bonds of Series A, B, C, D, E, F, G, H, J,
and K, and all Savings Notes, have reached final maturity and can only be redeemed.

 ITEM 3. Furnish the name and address where the bonds or check are to be mailed. If payment by direct deposit is preferred, do not provide
delivery instructions in Item 3. Instead, complete a direct deposit form, PD F 5396 or SF 1199A, and submit it with this application.
Forms SF 1199A are available at financial institutions in the United States. PD F 5396 is available for download on the Internet at
www.treasurydirect.gov. The financial institution designated to receive the payment can assist in the completion of the direct
deposit form.
 ITEM 4. Sign the form and provide your daytime telephone number. The signature of a registered owner should be in the same form as that
appearing on the bonds. The signature of a representative or fiduciary must be in the same form as that shown in the court papers
or other evidence of authority and must be followed by the proper title and reference to the estate, as for example, "John W. Smith,
administrator of the estate of Henry L. Smith, deceased."
 ITEM 5. Each person whose signature is required 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
impress the seal or stamp used when certifying requests for payment. Authorized officers are available at banking institutions,
including credit unions, in the United States. For a complete list of such officers, see Department of the Treasury Circulars No. 530,
current revision, and Public Debt Series No. 3-80.
WHERE TO SEND – Send the completed form and evidence, if any, to the Department of the Treasury, Bureau of the Public Debt, PO Box 7012,
Parkersburg, WV 26106-7012.
NOTICE UNDER THE 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; or 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 a completed form to this address; send to the address
shown in "WHERE TO SEND."

3

PD F 4239 E