Form PD F 4000 PD F 4000 Request to Reissue United States Savings Bonds

RESET
For official use only:
Customer Name

Customer No.

PD F 4000 E
Department of the Treasury
Bureau of the Public Debt
(Revised October 2012)

OMB No. 1535-0023

REQUEST TO REISSUE UNITED STATES SAVINGS BONDS

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

PART A – NEW BOND REGISTRATION
1. Bond Description (NOTE: Savings bonds within one month of final maturity cannot be reissued.)
I/We request reissue of the bonds described below, in the amount of $

(total face amount).
REGISTRATION

FACE
AMOUNT

ISSUE DATE

(Provide complete Social Security Number
[for example, 123-45-6789] and names,
including middle names or initials, on the bonds.)

BOND NUMBER

(If you need more space to describe your bonds, attach either a PD F 3500 [see www.treasurydirect.gov], a plain sheet of paper, or a photocopy.)

2. Extent of reissue:

In full

Amount, Fractional Share, or Percentage

3. Requested Registration
a. Taxpayer Identification No.:
(Social Security Number or Employer Identification Number)
b. Registration:
(First Name, Middle Name or Initial, Last Name, or Fiduciary Inscription)

c. Address:
(Street, Route, or PO Box; City, State, ZIP Code)
d. To name a coowner or beneficiary, select a box and enter a name:
coowner

beneficiary (POD)

}
(First Name, Middle Name or Initial, Last Name)

(If a name is shown and neither box is marked, coownership will be assumed.)
TAX LIABILITY: If the name of a living owner or principal coowner of the bonds is eliminated from the registration, the owner or principal coowner must
include the interest earned and previously unreported on the bonds to the date of the transaction on his or her Federal income tax return for the year of the
reissue. (Both registrants are considered to be coowners when bonds are registered in the form: "A" or "B.") The principal coowner is the coowner who
(1) purchased the bonds with his or her own funds, or (2) received them as a gift, inheritance, or legacy, or as a result of judicial proceedings, and had them
reissued in coownership form, provided he or she has received no contribution in money or money's worth for designating the other coowner on the bonds.
If the reissue is a reportable event, the interest earned on the bonds to the date of the reissue will be reported to the Internal Revenue Service (IRS) by a
Federal Reserve Bank or Branch or the Bureau of the Public Debt under the Tax Equity and Fiscal Responsibility Act of 1982. THE OBLIGATION TO
REPORT THE INTEREST CANNOT BE TRANSFERRED TO SOMEONE ELSE THROUGH A REISSUE TRANSACTION. If you have questions
concerning the tax consequences, consult the IRS, or write to the Commissioner of Internal Revenue, Washington, DC 20224. Unless we are otherwise
informed, the first-named coowner will be considered the principal coowner for the purpose of this transaction.

4. Delivery instructions, if
different from above:

(Name)
(Street, Route, or PO Box)
(City)

(State)

(ZIP Code)

PART B – REASON FOR REISSUE
Describe the reason for the reissue.

If the reason shown above is to correct an error in registration, provide the following information.
(1) Who purchased the bonds?
(2) Whose funds were used?
(3) How did the error occur?

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. I/We
agree to reissue of the bonds as indicated in Part A and certify that the reissue is authorized. I/We hereby bind ourselves, our heirs, legatees,
successors, and assigns, jointly and severally, to hold the United States harmless on account of the reissue requested herein, 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 application, to any party
having an ownership or entitlement interest in the bonds.

Sign in ink in the presence of an authorized certifying officer.
(See the instructions for who must sign.)

(Signature)

(Signature)

(Title)

(Title)

(Street, Route, or PO Box)

(Street, Route, or PO Box)

(City)

(State)

(ZIP)

(City)

(State)

(Social Security Number)

(Social Security Number)

(Email Address)

(Email Address)

(Daytime Telephone Number)

(Daytime Telephone Number)

(ZIP)

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. NOTE: To certify a second signature, use the next page.

I CERTIFY that

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

proven to me, personally appeared before me this

day of

in the year
(Month)

at

,
(Year)

, and signed this form.
(City, State)

(Signature and Title of Certifying Officer)

(OFFICIAL STAMP
(Name of Financial Institution)

OR SEAL)

(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 4000 E

, whose identity is known or was

I CERTIFY that
(Name of Person Who Appeared)

proven to me, personally appeared before me this

day of

in the year
(Month)

at

,
(Year)

, and signed this form.
(City, State)

(Signature and Title of Certifying Officer)

(OFFICIAL STAMP
(Name of Financial Institution)

OR SEAL)

(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)

Reserved for Identification Notations
Customer Account Number
and Date Established:_______________________________

Customer Account Number
and Date Established: _________________________________

Identified by: ______________________________________

Identified by:_________________________________________

Documents – Descriptions: ___________________________

Documents – Descriptions: ____________________________

INSTRUCTIONS TO CERTIFYING OFFICER
Each person appearing before you must establish identification by positive and reliable evidence before this form is signed, unless he or
she is personally known to you. You must place an adequate notation in the area reserved for identification notations in Part C or on a
separate record, showing exactly how identification was established. A notation is adequate if it is sufficiently detailed to permit, at a later
date, a determination of the exact identification actually used. You and, if you are an officer or employee of an organization, the
organization will be held fully responsible for the adequacy of the identification.
The signatures to the request must be executed in your presence. Fully complete and sign the certification form provided for your use for
each signature you witness.
If you are an employee (rather than an officer) authorized to certify signatures, insert the words “Authorized Signature” in the space
provided for the title. Insert the place and date, as required on the form, and impress the seal of your organization.

FOR FEDERAL RESERVE BANK USE ONLY
This transaction was a reportable event.
$

was reported under

for
(Social Security Number)

.
(Year)

This transaction was not a reportable event. No interest was reported.

3

PD F 4000 E

INSTRUCTIONS
USE OF FORM – Complete this form to reissue paper (definitive) Series EE, HH, and I United States Savings Bonds, Retirement Plan
Bonds, and Individual Retirement Bonds. A separate Part A must be used for each new form of registration. If you need more space for
any item, attach either a plain sheet of paper, a photocopy of the relevant section, or, for Part A, Section 1, a PD F 3500 (see
www.treasurydirect.gov). To request payment, sign the backs of the bonds instead of completing this form.
INCOMPETENT OR MINOR – A minor of sufficient age and competency to sign the request and to understand the nature of the
transaction may request reissue of the bonds. A minor under legal guardianship may not request reissue. An incompetent owner,
coowner, or beneficiary may not request reissue.
PART A – NEW BOND REGISTRATION
1. Describe the bonds to be reissued. If you need more space, attach either a PD F 3500 (see www.treasurydirect.gov), a plain sheet of
paper, or a photocopy.
2. Mark the box “In full” if the person listed in Item 3 is to receive the entire value of the bond(s) described in Item 1; or, if the
person listed in Item 3 is not to receive the entire value, mark the second box and provide the appropriate amount, fractional
share, or percentage he or she is to receive.
3. Provide the following information:
a. The appropriate Taxpayer Identification Number (Social Security Number or Employer Identification Number).
If the new bonds are to be inscribed in the name of . . .

Provide this . . .

One person as owner, with or without a beneficiary
Two persons as coowners

The Social Security Number of the owner
The Social Security Number of the first-named coowner

A guardian, custodian, or similar representative of the estate of
a minor, incompetent, or other ward

The Social Security Number of the minor, incompetent, or
other ward

Other fiduciary registration (trustee, administrator of decedent’s
estate, etc.)

The Social Security Number of the grantor of the trust or
decedent or an Employer Identification Number assigned to
the fiduciary estate

b. The new registration. Use as much space as necessary on these three lines to give either a name (first name, middle
name or initial, and last name) or a fiduciary inscription.
c. Mailing information.
d. To add a coowner or beneficiary, mark the appropriate box and insert his or her name. If a name is shown and no box is
marked, coownership will be assumed.
4. To have the bonds mailed to an address other than the address shown in Item 3, provide the name and address of the
person or institution receiving them.

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 the above address; send to correct address
shown in “Where to send” in the Instructions.

4

PD F 4000 E

PART B – REASON FOR REISSUE
Describe the reason for the reissue. The chart below shows common reasons for reissue. These may not be authorized for all
series. Complete guidelines for authorized reissue transactions may be found in the regulations, in the following Department
Circulars: DC 3-80 (Series EE/HH), DC 2-98 (Series I), DC 1-75 (Individual Retirement Bonds), and DC 1-63 (Retirement Plan
Bonds).
Bonds may be reissued to…
Add a new coowner or beneficiary to
a bond in sole owner registration.
Change the present beneficiary to
coowner.
Remove the name of a living
beneficiary.
Remove the name(s) of any
deceased registrant(s).

Show that
occurred.

a

change

of

name

Correct an error in registration.

Substitute the name of the fiduciary
who has succeeded the fiduciary
named in the registration of the
bonds.

The form must be signed by…
The owner.
The owner.
The owner.
The surviving registrant.

The person whose name has changed.

The purchaser.
If the purchaser and the person whose
funds were used to purchase the
bonds are different persons, both must
sign.
The successor in his or her fiduciary
capacity.

Show the name of the executor or
administrator of a deceased owner’s
estate.

The fiduciary in his or her fiduciary
capacity.

Show the name of the guardian,
conservator, or similar representative
of the estate of a minor or
incompetent owner.
Change ownership due to divorce,
legal separation, or annulment.

The fiduciary in his or her fiduciary
capacity.

The owner or both coowners (or their
representatives).

Additional Information
The original owner must be the first-named
coowner.
The beneficiary may only be shown as secondnamed coowner.
The owner may add a different person as coowner
or beneficiary.
The surviving registrant must be shown as the
owner or first-named coowner in the registration of
the new bonds. If more than one registration is
requested, a separate Part A must be completed for
each different registration. Submit certified copies
of the death certificates for all deceased registrants
except beneficiaries on Series EE, HH, or I bonds.
Explain exactly how the change of name was
authorized (marriage, divorce, court order,
naturalization, etc.). Evidence may be required.
Provide the answers to the questions shown.

Submit proof of the succession to the position, such
as a certified copy of the letters of appointment or,
in the case of a trustee, a copy of the trust
instrument and proof of the death or resignation of
the original trustee.
Submit a certified copy of the letters of appointment,
dated within one year of submission, and certified
copies of the death certificates for all deceased
registrants.
Submit a certified copy of the letters of appointment,
dated within one year of submission.

See the Tax Liability statement on this form. The
name of another person may be added as coowner
or beneficiary.

For bonds in coownership form, a
request solely to eliminate the name of
one coowner may be signed by that
coowner only.

Remove a living owner/coowner and
reissue in a form authorized under
the regulations.

The owner/coowner being removed.

5

Remaining registrant must be named first in the
registration. See the Tax Liability statement on this
form. The name of another person may be added
as coowner or beneficiary.

PD F 4000 E

PART C – SIGNATURES AND CERTIFICATIONS
SIGNATURES - Sign the form in ink, in the presence of an authorized certifying officer. The form must be signed as indicated in Part B of
the instructions. 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.
If an owner or coowner's name has been changed by marriage, divorce, court order, naturalization, or otherwise, he or she must sign the
form as follows: " (PRESENT LEGAL NAME) ", changed by (specify manner in which change occurred) from " (NAME AS ON
BONDS)." To support a change of name, other than by marriage, a complete statement should follow the signature to show exactly how
the change of name was authorized. Evidence may be required.
CERTIFICATION – Each person whose signature is required must appear before and establish identification to the satisfaction of an
authorized certifying officer. If a minor owner or coowner signs the request, the officer must be satisfied that the minor is of sufficient
competency to understand the nature of the transaction. 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:
SIGNATURE GUARANTEED
ABC National Bank
Hillview Branch

Acceptable certification for a brokerage:
SIGNATURE GUARANTEED
MEDALLION GUARANTEED
Generic Brokerage

Authorized Signature

Authorized Signature
XXXXXXXX
SECURITIES TRANSFER AGENTS MEDALLION PROGRAM
[Bar Code]

ADDITIONAL REQUIREMENTS FOR SERIES HH BONDS:


Under the Interest Dividend Tax Compliance Act of 1983 as implemented by Internal Revenue Service regulations, the new
owner or first-named coowner must complete IRS Form W-9 to certify that the Social Security Number furnished is correct,
to indicate whether or not he or she is subject to backup withholding under the provision of Section 3406(a)(1)(C) of the
Internal Revenue Code, and to verify that he or she is a United States person (including a U.S. resident alien). Forms W-9
are available at financial institutions in the United States and Internal Revenue Offices. These forms can also be found on
the IRS website at www.irs.gov.



The furnishing of direct deposit information is a condition of reissue of Series HH bonds bearing issue dates of October
1989 and thereafter. A direct deposit form (PD F 5396, at www.treasurydirect.gov) or SF 1199A must be completed for
Series HH bonds dated October 1989 and thereafter which are submitted for reissue. The direct deposit form must be
completed by the new owner or coowner providing the appropriate information for direct deposit of the semi-annual interest
payments. Forms SF 1199A are available at financial institutions in the United States. PD F 5396 is available for download
on the Internet using the "Forms" link at www.treasurydirect.gov. The financial institution designated to receive the payment
can assist in the completion of the direct deposit form.

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 the evidence submitted with this form is to be returned, provide a written request when the evidence is
submitted.
WHERE TO SEND – Unless otherwise instructed, send PD F 4000 and the bonds, as well as any other appropriate forms and
evidence, to either of these addresses:
Bureau of the Public Debt
PO Box 7012
Parkersburg, WV 26106-7012

Treasury Retail Securities Site
PO Box 214
Minneapolis, MN 55480-0214
(Phone: 800-553-2663)

OR

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PD F 4000 E