Form 5354 FHA Transaction Request

RESET

PD F 5354E
Department of the Treasury
Bureau of the Public Debt
(Revised January 2003)

OMB No. 1535-0120

FHA TRANSACTION REQUEST

HUD ACCOUNT IDENTIFICATION

FOR DEPARTMENT USE

ACCOUNT NUMBER

ENTERED BY

ACCOUNT NAME
APPROVED BY

DATE APPROVED

TRANSACTIONS REQUESTED

CHECK THE BOX NEXT TO EACH TRANSACTION REQUESTED AND PRINT THE
INFORMATION AS IT SHOULD APPEAR ON YOUR HUD ACCOUNT.

NAME CHANGE (Signature certification may be required)

ADDRESS CHANGE

State

City

ZIP-CODE

TAXPAYER IDENTIFICATION NUMBER CHANGE (For correction only)
1ST NAMED
OWNER
SOCIAL SECURITY NUMBER

EMPLOYER IDENTIFICATION NUMBER

TELEPHONE NUMBER CHANGE

(

)

DIRECT DEPOSIT INFORMATION

ADD

ROUTING NUMBER

CHANGE (Signature certification required)

(Limit 9 characters)

FINANCIAL INSTITUTION NAME

(Limit 30 characters)
(Limit 17 characters) ACCOUNT TYPE

ACCOUNT NUMBER
ACCOUNT NAME

(Limit 22 characters)

CHECKING

(Check One)

CONSOLIDATION OF HUD ACCOUNTS

CLOSING HUD ACCOUNT NUMBER(S)
SEE INSTRUCTIONS FOR PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE

SAVINGS

AUTHORIZATION
NOTE: IF YOUR SIGNATURE REQUIRES CERTIFICATION, DO NOT SIGN THIS FORM UNTIL YOU ARE IN THE PRESENCE OF A
CERTIFYING OFFICER. SIGN YOUR NAME EXACTLY AS IT CURRENTLY APPEARS ON YOUR ACCOUNT.
I SUBMIT THIS REQUEST PURSUANT TO THE PROVISIONS OF 31 CFR PART 306 AND 31 CFR PART 337.
UNDER PENALTIES OF PERJURY, I CERTIFY THAT THE INFORMATION PROVIDED ON THIS FORM IS TRUE, CORRECT AND
COMPLETE.
FOR TAXPAYER IDENTIFICATION NUMBER CHANGES ONLY: Under penalties of perjury l certify that the number shown on this form
is my correct Taxpayer Identification Number and that I am not subject to backup withholdings because (1) I have not been notified that I
am subject to backup withholding as a result of a failure to report all interest or dividends, or (2) the Internal Revenue Service has notified
me that I am no longer subject to backup withholding.

SIGNATURE(S)

DATE

TITLE (IF APPROPRIATE)

CERTIFICATION
SIGNATURE CERTIFICATION IS REQUIRED FOR CERTAIN NAME CHANGES AND ALL DIRECT DEPOSIT INFORMATION
CHANGES.
I CERTIFY THAT THE ABOVE-NAMED PERSON(S) AS DESCRIBED, WHOSE IDENTITY IS KNOWN OR PROVEN TO ME,
PERSONALLY APPEARED BEFORE ME THIS

DAY OF

MONTH/YEAR

AT

CITY/STATE

AND SIGNED THIS REQUEST.

SIGNATURE AND TITLE OF CERTIFYING INDIVIDUAL
OFFICIAL SEAL
OR STAMP
(SUCH AS
CORPORATE SEAL,
SIGNATURE
GUARANTEED
STAMP, OR
MEDALLION STAMP).

NAME OF FINANCIAL INSTITUTION

ADDRESS

CITY/STATE

CERTIFICATION BY A NOTARY PUBLIC IS NOT ACCEPTABLE.

INSTRUCTIONS FOR COMPLETING
AN FHA TRANSACTION REQUEST

PURPOSE
You may use this form to request changes to any of the following information for your HUD account:
• name,
• address,
• taxpayer identification number,
• telephone number, or
• direct deposit information.
You may also use this form to request the consolidation of two or more HUD accounts into a single HUD account.

IMPORTANT NOTICES
This form cannot be used to transfer debentures.
Unless all the required information is provided legibly, there may be a delay in processing your request. To avoid delays, read the
instructions carefully and print clearly in ink only.

HUD ACCOUNT IDENTIFICATION
Provide your HUD ACCOUNT NUMBER and ACCOUNT NAME. You will find this information on your HUD Statement of Account.

TRANSACTIONS REQUESTED

NAME CHANGE (See CERTIFICATION instruction)
Check this box to change the name that currently appears on your account. Provide the complete account name as it should appear.
You may not use this form to remove the first-named owner from your account, but you may use this form to add or remove the name of
a second owner or beneficiary.

TAXPAYER IDENTIFICATION NUMBER CHANGE (For correction only)
Check this box to correct the taxpayer identification number that currently appears on your account. Provide the correct number for the
first-named owner.
DIRECT DEPOSIT INFORMATION CHANGE (Signature certification required)
Check this box to change the direct deposit information that currently appears on your account. Provide the complete direct deposit
information as it should appear, including:
• ROUTING NUMBER (your financial institution’s ABA identifying number)
• FINANCIAL INSTITUTION NAME (the name of the institution to which payments are to be sent)
• ACCOUNT NUMBER (the account number at your financial institution)
• ACCOUNT TYPE (checking or savings)
• ACCOUNT NAME (the name as it appears on the account at your financial institution)
• If both the HUD account and the receiving financial institution account are in the names of individuals then at least
one of the individuals named on the HUD account must be named on the deposit account at the receiving financial
institution.

CONSOLIDATION OF HUD ACCOUNTS
Check this box to consolidate two or more of your HUD accounts. All HUD accounts to be consolidated must have the same name,
address, taxpayer identification number and direct deposit instructions. Provide the number(s) of the account(s) from which
debentures are to be moved.

AUTHORIZATION
Sign and date the request form. Identification may be required. If this account is jointly owned (i.e., John Smith and Mary Smith), both
owners must sign the request. If you are requesting a change to a social security number, this form must be signed by the first-named
owner (whose social security number is shown) or accompanied by IRS Form W-9 completed by the first-named owner. If the IRS has
notified you that you are subject to backup withholding and you have not received notice from the IRS that backup withholding has
terminated, you should strike out the language certifying that you are not subject to backup withholding.

CERTIFICATION
Certification of your signature is required if you add or delete a beneficiary or second owner or if you change the direct deposit
information. Acceptable certifying individuals include authorized employees of insured depository institutions and corporate central credit
unions. Certification by a notary public is not acceptable. All other transactions do not require that your signature be certified.

SUBMISSION
Submit this request to:

Bureau of the Public Debt
Special Investments Branch
200 Third Street
P.O. Box 396
Parkersburg, WV 26106-0396

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Telephone Number: (304) 480-5299
Fax Number: (304) 480-5277
Internet Address: http://www.publicdebt.treas.gov/spe/spe.htm
E-Mail Address: [email protected]

CONFIRMATION OF THE TRANSACTION
You will receive a HUD Statement of Account after your transaction has been processed.

NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS

We’re asking for the information on this form to assist us in processing your securities transaction requests. Our authority comes from 31
U.S.C. Ch. 31 which authorizes the Treasury Department to borrow money to pay the public debt of the United States. Also, 26 U.S.C.
6109 requires us to use your SSN on certain forms when we report taxable income to IRS. It’s voluntary that you provide the requested
information, but without it, we may not be able to process your transaction requests. Information concerning your securities holdings and
transactions is considered confidential under Treasury regulations (31 CFR Part 323) and the Privacy Act. However, the following routine
uses of this information may include disclosure to the following persons or entities: agents and contractors who help us manage the public
debt; others entitled to the securities or payment; agencies (including disclosure through approved computer matches) determining eligibility for benefits, finding persons we’ve lost contact with, or helping us collect debts; agencies for investigations or prosecutions; courts,
counsel, and others for litigation and other proceedings; a Congressional office asking on your behalf; and as otherwise authorized by law.
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.