Form PD F 1832 E PD F 1832 E Special Form of Assignment for U.S. Registered Definitiv

RESET
For official use only:
Customer Name

Customer No.

PD F 1832 E
Department of the Treasury
Bureau of the Public Debt
(Revised May 2011)

OMB No. 1535-0059

SPECIAL FORM OF ASSIGNMENT FOR
U.S. REGISTERED DEFINITIVE SECURITIES

WARNING: Use only for securities in certificate form (NOT book-entry). This form by itself has no monetary value and is NOT evidence of ownership of
these securities. This form will not support a transaction unless accompanied by the securities (except for securities previously tendered).

1.

Identification of Securities

CUSIP
(Title of Securities)

TITLE OF SECURITY
(Identify by interest rate, title, call
and maturity dates)

2.

SERIAL NUMBER

REGISTRATION
(Exact inscription on each security)

FACE AMOUNT

For value received, I assign to the Secretary of the Treasury for: (Select only one)
a.

Conversion to book-entry and deposit in TreasuryDirect® account number

,

registered
b.

Conversion to book-entry and deposit with
(Name of Commercial Financial Institution)

ABA Routing Number (nine digits)
Account/Instructions

c.

Payment of matured/called securities to another party:
(Name of Payee)

d.
3.

Other:

I am the owner or the authorized representative of the owner of the securities described on this form. I authorize discharge of the
registrations on the books of the Department of the Treasury.
Are additional securities described on an attached sheet?

Yes

No

(You must check one box.)

You must wait until you are in the presence of a certifying officer to sign this form.

Sign Here:
(Signature by or on behalf of owner)

(Additional signature if required)

Certifying Officer – The individual must sign in your presence. Complete the certification and affix your stamp or seal.
I CERTIFY that

whose identity (or the identity of each of whom) is known or was
(Name/Names)

proven to me, personally appeared before me the

,

day of
(Month)

,

at
(City)

and signed this assignment.

(State)

(OFFICIAL STAMP
OR SEAL)

(Signature and title of certifying officer)

(Address)

A notary public may not certify this request.

,
(Year)

INSTRUCTIONS
USE OF FORM
Use PD F 1832 to certify assignments of U. S. registered definitive securities. It is appropriately used only at the discretion of the
Bureau of the Public Debt in one of the following circumstances:





To correct a defective assignment already made on the back of a registered definitive security;
To accommodate owners required to sign a large number of registered definitive securities; or
To obtain the assignment of two or more geographically separated assignors.

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

IDENTIFICATION OF SECURITIES
Furnish the title of the securities and all identifying information shown on the face of the securities. The title of the
securities includes the interest rate, type of security (note, bond, etc.), letter series if a note, call year if applicable, and
maturity year. Show the CUSIP and furnish the face amount, serial number, and inscription of each security. If additional
space is needed to identify other securities with the same inscription, attach another sheet and indicate this by marking
the appropriate box in Item 3.

ITEM 2.

ACTION REQUESTED
Investors may use PD F 1832 for the transactions listed in Items 2a through 2d. Check the appropriate box for the
transaction desired. Only one transaction may be requested; a separate request must be completed for each transaction.
a. Convert the definitive (paper) registered securities to an account in TreasuryDirect®. Furnish the TreasuryDirect
account number and registration. There is no charge for conversion.
b. Convert the definitive (paper) registered securities to a book-entry account with a commercial financial institution.
Furnish the name of the institution, the nine-digit ABA Routing Number which identifies the institution, account
information, and any special instructions for delivery.
c. Allow matured or called definitive (paper) registered securities to be paid to another party. The payee must execute
IRS Form W-9 and submit it with the securities.
d. Request any other authorized transaction. Provide the type of transaction and any other appropriate information.

ITEM 3.

AUTHORIZATION AND CERTIFICATION
You must sign the form in the presence of an authorized certifying individual. You must also check the appropriate box to
show whether additional securities are described on an attached sheet. If another sheet is attached for identification of
other securities, you must initial and date that sheet.
The certifying individual must complete the certification section. Authorized certifying officers are available at financial
institutions, including credit unions, in the United States. A notary public is not an acceptable certifying officer. Additional
forms may be used, if necessary, to accommodate more than two owners. If joint owners of a security are in different
locations, each person may complete a separate PD F 1832 in the presence of an authorized certifying individual.

ADDITIONAL INFORMATION – For a complete list of authorized certifying officers, a copy of the regulations, additional forms, or
other information, contact the office shown in "WHERE TO SEND" in the Instructions. If you prefer, call us at 304-480-7711.

WHERE TO SEND – Send the completed form, and any additional information or evidence, to the Department of the Treasury,
Bureau of the Public Debt, PO Box 426, Parkersburg, WV 26106-0426.
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 15 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.