Form PD F 2481 PD F 2481 Application for Recognition as a natural guardian of nim

OMB No.1535-0105
PD F 2481 E
APPLICATION FOR RECOGNITION AS NATURAL GUARDIAN OF
Department of the Treasury
MINOR NOT UNDER LEGAL GUARDIANSHIP AND FOR
Bureau of the Public Debt
(Revised July 2012)
DISPOSITION OF MINOR’S INTEREST IN REGISTERED SECURITIES
Visit us on the Web at 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 under the laws of the United States.
PRINT IN INK OR TYPE ALL INFORMATION

1. DESCRIPTION OF SECURITIES
TITLE OF SECURITY
(Identify by interest rate, title, call and maturity dates)

FACE AMOUNT
(Denomination)

SERIAL NUMBER

REGISTRATION
(Exact inscription on each security)

2. MINOR
NAME:
SOCIAL SECURITY NUMBER:
DATE OF BIRTH:
3. GUARDIAN
I request that I be recognized as natural guardian of the minor and request disposition and assignment of the described
securities as follows:
Conversion to book-entry form for the account of

(Account Information)

Payment of called or matured securities
NAME:
ADDRESS:
TELEPHONE:
RELATIONSHIP TO MINOR:

PARENT

FURNISH CHIEF SUPPORT

OTHER (specify)

MARRIED? If your spouse did not apply as natural guardian with you, your spouse must sign after the following statement:
I consent to the above-named parent acting as the guardian for our minor child.

Signature

SEPARATED OR DIVORCED? You must furnish a certified copy of court records showing you have custody of the minor.
If you checked “FURNISH CHIEF SUPPORT,” please provide names and addresses of others who regularly contribute to the
minor’s support, and the percentage of their contributions:

Does the minor reside with you?

Yes

No

If no, provide the name and address of the person with whom the minor resides:

4. AUTHORIZATION

You must wait until you are in the presence of a certifying officer to sign this form.
(If there are two owners joined by the word “and,” both must sign.)

I request that I be recognized as natural guardian of the said minor for purposes of furnishing the payment instructions for the
security(ies) listed and to execute any necessary requests for those security(ies).
I certify that no legal guardian or similar representative has been appointed for the said minor and no such application is
contemplated and that the said minor has an interest in whole or in part in securities held in the accounts listed.
In consideration for my recognition as natural guardian of the minor, I agree that I will promptly notify the Bureau of the Public Debt
if (a) the minor reaches the age of majority or is emancipated by court order or marriage under the laws of the state of his or her
residence, (b) a legal guardian or similar representative is appointed for the minor’s estate, (c) I no longer furnish chief support for
the minor (when support is the basis for recognition), or (d) the minor dies.

SIGNATURE

SIGNATURE (IF NECESSARY)

5. CERTIFICATION The signature(s) in section 4 above MUST be certified by an authorized certifying officer.

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(ies) is/are

NAME(S) OF PERSON(S) WHO APPEARED

known or proven to me, personally appeared before me this
at
CITY/STATE

ACCEPTABLE CERTIFICATIONS:

day of

MONTH/YEAR

and signed this form.

SIGNATURE AND TITLE OF CERTIFYING OFFICER

Financial Institution’s Official Seal or
Stamp (Such as Corporate Seal,
Signature Guaranteed Stamp, or
Medallion Stamp). Brokers must
use a Medallion Stamp.

NAME OF FINANCIAL INSTITUTION

ADDRESS

CITY/STATE/ZIP CODE

TELEPHONE

RESET

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PD F 2481 E

PD F 2481 E
Department of the Treasury
Bureau of the Public Debt
(Revised July 2012)

INSTRUCTIONS FOR COMPLETING
APPLICATION FOR RECOGNITION AS NATURAL GUARDIAN OF
MINOR NOT UNDER LEGAL GUARDIANSHIP AND FOR
DISPOSITION OF MINOR’S INTEREST IN REGISTERED SECURITIES

PURPOSE
This form can be used to:
• apply for recognition as a natural guardian of a minor who owns, wholly or in part, registered securities in an estate
where a legal representative has not been appointed.
• apply for recognition as a natural guardian when a designated natural guardian is no longer acting. (A death certificate,
physician’s certificate, or certified evidence of court action must be submitted as proof of the designated natural guardian’s
inability to act.)
IMPORTANT NOTE
• Only original signatures and forms will be accepted (stamped signatures are not acceptable).
• Unless all the required information is provided legibly, there may be a delay in processing this form. To avoid delays, read the
instructions carefully and type or print clearly in ink only.
• This form MUST be signed in all cases.
• APPLICATIONS WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS.
WHO MAY APPLY
• The parent with whom the minor resides may apply. If the minor resides with both parents, either or both may apply. The parent who
has not joined in the application must consent by signing the statement within the box in Section 3. If the parents are separated or
divorced, no consent is required provided that a certified copy of court records is furnished showing that the parent applying has
custody.
• If the minor does not reside with either parent, the person who furnishes the minor’s chief support may apply.
No application will be considered if the Department of the Treasury is on notice that 1) the minor has reached the age of majority or is
emancipated by court order or marriage under the laws of the state of his/her residence, 2) a legal guardian or similar representative
of the minor’s estate has been appointed, 3) the applicant is not entitled to act as natural guardian, or 4) the minor has died.
1. DESCRIPTION OF SECURITIES
Provide a complete description of all securities owned wholly or in part by the minor.
2. MINOR
Provide the minor’s name, Social Security Number, and date of birth.
3. GUARDIAN
Check the appropriate box to show the requested disposition of the security(ies).
Provide your name and address, and indicate your relationship to the minor. Remember: If you are married and your
spouse did not apply as natural guardian with you, your spouse must sign the statement within the box. If you’re separated
or divorced, furnish a certified copy of court records showing you have custody of the minor.
If you are applying as the furnisher of chief support for the minor, provide the names and addresses of others who regularly
contribute to the minor’s support and the extent of their contributions (expressed as a percentage of the minor’s total support).
Indicate whether the minor resides with you. If not, provide the name and addresses of the person with whom the minor resides.
4. AUTHORIZATION
Read the authorization statement carefully. In the presence of an authorized certifying officer, sign the form in ink.
5. CERTIFICATION
Certification of your signature is required. Acceptable certifying officers include authorized employees of insured depository institutions
and corporate central credit unions.

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PD F 2481 E

WHERE TO SEND
After completing and signing the application, submit it, together with the securities and any necessary evidence, to the Department
of the Treasury, Bureau of the Public Debt, PO Box 426, Parkersburg, WV 26106-0426. We suggest that you send the securities by
registered mail.
FEE FOR BONDS OR NOTES REQUESTED IN CERTIFICATE FORM
A fee is charged for each Treasury bond or note requested in certificate form. Unless we are specifically instructed otherwise, any
unmatured securities will be converted to TreasuryDirect®.
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; 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 completed form to this
address; send to the address shown in “WHERE TO SEND” in the Instructions.

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PD F 2481 E