Form PD F 5178 PD F 5178 Transaction Request

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PD F 5178 E
Department of the Treasury
Bureau of the Fiscal Service
(Revised October 2013)

Legacy Treasury Direct®

OMB No. 1535-0069

TRANSACTION REQUEST
www.treasurydirect.gov

Call us at 800-722-2678

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

This form will not be accepted if it has any alterations or corrections.

1. LEGACY TREASURY DIRECT ACCOUNT INFORMATION
Legacy Treasury Direct ACCOUNT NUMBER:
ACCOUNT NAME:

2. TRANSACTIONS REQUESTED

Mark the box next to each transaction requested and show the information as it should
appear on your Legacy Treasury Direct account.

CONSOLIDATION OF LEGACY TREASURY DIRECT ACCOUNTS - For identical accounts only. Provide the
number(s) of the account(s) from which securities are to be moved and the number of the account into which they are to be
deposited.
Legacy Treasury Direct Account Number(s) to be closed:


Surviving Legacy Treasury Direct
Account No.

NAME CHANGE - Provide the complete account name as it should appear (see Items 2 and 3 in the instructions). This
type of change usually requires a certified signature.

ADDRESS CHANGE - Provide the complete address as it should appear.

TELEPHONE NUMBER CHANGE - Provide each complete number, including extension, if applicable.
(Daytime Telephone Number)

(Alternate Telephone Number)

PAYMENT INFORMATION CHANGE - Provide the complete direct deposit or debit information as it should appear.
This change requires a certified signature; see Items 2 and 3 in the instructions.
Financial Institution’s Routing No.:
(Financial Institution's Name)

(Financial Institution's Telephone No.)

(Name[s] on Financial Institution Account)
Account No. at
Financial Institution:

Type:

Checking

Savings

TAXPAYER IDENTIFICATION NUMBER CORRECTION - Use only for a correction. Provide the correct number.
(First-Named Owner's Social Security Number)

OR

(Owner's Employer Identification Number)

3. SIGNATURES AND CERTIFICATION
Under penalties of perjury, I/we certify that the information provided on this form is true, correct, and complete. I certify that I have the
authority to authorize financial transactions using the bank information described on this form. This request is submitted pursuant to
the provisions of the Department of the Treasury Circulars, PD Series Nos. 2-86 (31 CFR Part 357) and 1-93 (31 CFR Part 356). I
agree to indemnify and hold the United States harmless in the event of any loss that results from this request.
For Taxpayer Identification Number corrections, I certify under penalty of perjury that:
1. The Taxpayer Identification Number shown is my correct Taxpayer Identification Number (or I am waiting for a number to be
issued to me), and
2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the
Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or
(c) I have been notified by the Internal Revenue Service that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien). (For a definition, see "INSTRUCTIONS.")
Note: You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return.
The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup
withholding.
If a certified signature is required, you must wait until you are in the presence of a certifying individual to sign and date this form.
If there are two owners joined by the word "and," both may have to sign (see the instructions).

Sign Here: 
(Signature)

(Title, if appropriate)

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

(City)

(State)

(ZIP Code)

Date:
(Daytime Telephone No.)

Sign Here: 
(Signature)

(Title, if appropriate)

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

(City)

(State)

(ZIP Code)

Date:
(Daytime Telephone No.)

Instructions to Certifying Individual:
1. Name of person(s) who appeared and date of appearance MUST be completed. NOTE: For a second person, use Page 3.
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(s) of Person(s) 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 Individual

(OFFICIAL STAMP
OR SEAL)

Name of Financial Institution

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.

Address

City / State / ZIP Code

(Notary certification is NOT acceptable.)
Telephone

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, whose identity is known or was

I CERTIFY that
Name(s) of Person(s) 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 Individual

(OFFICIAL STAMP
OR SEAL)
Name of Financial Institution

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.

Address

City / State / ZIP Code

(Notary certification is NOT acceptable.)

Telephone

INSTRUCTIONS
PURPOSE OF FORM – Use this form to request consolidation of two or more Legacy Treasury Direct accounts into a single Legacy
Treasury Direct account, or to request changes or corrections to any of the following information for your Legacy Treasury Direct account:


Name



Telephone number(s)



Address



Payment information



Taxpayer Identification Number
(correction only)

IMPORTANT NOTICES


This form can't be used to transfer securities.



Only original signatures will be accepted (stamped signatures are not acceptable).



If you are a corporation with a governing body, a resolution or a PD F 1010 must accompany this form. (For PD F 1010, go to
www.treasurydirect.gov.)



If any person signing this form is acting in a fiduciary capacity, failure to provide legal evidence may delay processing.



This form must be signed in all cases. Certification of the signature is required if you add or delete a beneficiary or secondnamed owner, if you change the payment information, if you change your name (other than a minor change) and don't submit
supporting evidence, if you change your registration from an individual account to your grantor trust, or if you change your
registration from a grantor trust to an individual account.

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COMPLETION OF FORM – Print clearly in ink or type all information requested.
ITEM 1.

LEGACY TREASURY DIRECT ACCOUNT INFORMATION

Provide your Legacy Treasury Direct Account Number. Your Legacy Treasury Direct Account Number is shown on your Statement
of Account, immediately above the Account Holdings section. Provide the name(s) under which the account is registered; this is
shown in the address block of your Statement of Account.

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ITEM 2.

TRANSACTIONS REQUESTED

Mark all of the boxes that apply and provide the information requested.


CONSOLIDATION OF Legacy Treasury Direct ACCOUNTS – Mark this box to consolidate two or more of your Legacy
Treasury Direct accounts. All Legacy Treasury Direct accounts to be consolidated must be identical; the accounts must have
the same name, address, Taxpayer Identification Number, and payment information. Provide the number(s) of the account(s)
from which securities are to be moved in the spaces provided under "Legacy Treasury Direct Account Number(s) to be closed:",
and provide the number of the account into which the securities are to be deposited on the line above "Surviving Legacy
Treasury Direct Account No."



NAME CHANGE – Mark this box to change the name that currently appears on your account. Provide the complete account
name as it should appear. (Note: A minor may not register an account or purchase securities in his or her name alone.)


You may NOT use this form to remove the first-named owner from your account.



You may use this form to add or remove the name of a second-named owner or beneficiary; a certified signature is
required for this type of change.



You may use this form to change your registration to or from a trust IF the Taxpayer Identification Number
is NOT changing. If you are changing the registration to a trust, provide the name of the grantor, name(s) of the
trustee(s), and date on which the trust was created. If you want to change your registration to a trust and a
different Taxpayer Identification Number will be used, open an account in TreasuryDirect and transfer the
securities to the TreasuryDirect account with a Security Transfer Request (PD F 5179). (For PD F 5179, go to
www.treasurydirect.gov.)



Minor name corrections, such as misspellings, adding or deleting a middle name or initial, or substituting a
common nickname require your signature, but the signature doesn’t have to be certified.



Name changes due to marriage must be signed "(current name) changed by marriage from (former name)" and,
unless you submit a copy of your marriage certificate, your signature must be certified. For name changes not due
to marriage, you must submit a certified copy of the legal document showing the name change. If supporting
evidence is submitted, your signature to the form does not have to be certified.



ADDRESS CHANGE – Mark this box to change the address that currently appears on your account. Provide the complete
address as it should appear.



TELEPHONE NUMBER CHANGE – Mark this box to change the telephone number or numbers that currently appear on your
account. Provide the correct number or numbers, including area codes and, if appropriate, your extension.



PAYMENT INFORMATION CHANGE – Mark this box to change the direct deposit or debit information that currently appears
on your account. If both the Legacy Treasury Direct account and the receiving financial institution account are in the names of
individuals, then at least one of the individuals named on the Legacy Treasury Direct account must be named on the deposit
account. NOTE: Check with your financial institution to verify that your account can accept debit transactions.
Provide the complete direct deposit or debit information as it should appear:







Financial Institution’s Routing No. – Show your financial institution's ABA identifying number. This is the
routing/transit number which identifies the institution. You may need to contact the financial institution to obtain
this number.
Financial Institution's Name – Show the name of the financial institution.
Financial Institution's Telephone Number – Show the telephone number of the financial institution.
Name(s) on the Account – Show the name or names as they appear on the account at your financial institution.
Account No. at Financial Institution – Show your account number at the financial institution.
Type – Mark the appropriate box to indicate whether the account is "checking" or "savings."

A certified signature is required for any payment information change.


TAXPAYER IDENTIFICATION NUMBER CORRECTION – Mark this box to correct the Taxpayer Identification Number that
currently appears on your account. Provide the correct number for the first-named owner.

ITEM 3.

SIGNATURES AND CERTIFICATION

SIGNATURES – This form must be signed in all cases. The owner named on the Legacy Treasury Direct account, his or her
authorized representative, or the person entitled to the account must sign the form in ink, date it, and provide his or her title (if
applicable), home address, and daytime telephone number. If there are two owners joined by the word "and," both must sign
this form if it involves a name change (other than a minor change), payment information change, or consolidation of
accounts. If a correction of the Taxpayer Identification Number is requested, the form must be signed by the first-named
owner whose Taxpayer Identification Number is shown.
Certification of the signature is required if you add or delete a beneficiary or second owner, if you change the payment information,
if you change your name (other than a minor change) and don't submit supporting evidence, if you change your registration from an
individual account to your grantor trust, or if you change your registration from a grantor trust to an individual account. You must
wait until you are in the presence of a certifying individual to sign and date this form.
If the account is registered in the name of an organization or corporation, a current Resolution for Transactions Involving Treasury
Securities (PD F 1010) or your own corporate resolution must be submitted with this request. (For PD F 1010, go to
www.treasurydirect.gov.)
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ITEM 3.

SIGNATURES AND CERTIFICATION (continued)

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:


An individual who is a U.S. citizen or U.S. resident alien,



A partnership, corporation, company, or association, created or organized in the United States or under the laws of the United
States,



An estate (other than a foreign estate), or



A domestic trust (as defined in Regulations section 301.7701-7).

CERTIFICATION – If certification is applicable, each person whose certified signature is required must appear before and establish
identification to the satisfaction of an authorized certifying individual and sign and date the form in the individual’s presence. The
certifying individual must fully complete the certification blocks provided and affix the seal or stamp which is used when certifying
requests for payment. Acceptable certifications include a Financial Institution’s Official Seal or Stamp (such as Corporate Seal,
Signature Guaranteed Stamp, or Medallion Stamp). Brokers must use a Medallion Stamp (original signature is required).
Authorized certifying individuals include authorized employees of insured depository institutions and corporate central credit unions.
For a complete list of such individuals see Department of the Treasury Circular No. 300, 31CFR Part 315.
Please note that certification by a notary public is NOT acceptable.
WHERE TO SEND – Send the completed form to:
Treasury Retail Securities Site
P.O. Box 9150
Minneapolis, MN 55480-9150
To ensure timely processing, this form must be received at least ten business days in advance of:
 the maturity date of the security, and
 an interest payment date for the security.
CONTACT – Call us toll-free in the United States at 800-722-2678. Outside the U.S.? Call us at 304-480-6464.
CONFIRMATION OF TRANSACTION(S) – You will receive a Legacy Treasury Direct Confirmation of Change in Investor Account
Information after your transaction has been processed. A Statement of Account will be sent for each account when Legacy Treasury
Direct accounts are consolidated.
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 Fiscal Service 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, the Fiscal Service 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 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 Fiscal Service, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form to this
address; send to the address shown in "WHERE TO SEND" in the Instructions.

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