Form FS Form 1455 FS Form 1455 REQUEST BY FIDUCIARY FOR DISTRIBUTION OF UNITED STATES T

RESET
For official use only:
Customer Name

Customer No.

FS Form 1455
Department of the Treasury
Bureau of the Fiscal Service
(Revised July 2015)

REQUEST BY FIDUCIARY FOR DISTRIBUTION OF
UNITED STATES TREASURY SECURITIES

OMB No. 1530-0035

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

One or more fiduciaries (individual or corporate) must use this form to request distribution of United States Treasury Securities to the
person lawfully entitled due to distribution of a trust or an estate or other reasons set out in the instructions.
PART A – REASON FOR DISTRIBUTION
I/We request distribution of the securities and/or related payments for the following reason:
Distribution of trust
Reason for distribution:
Distribution of an estate to person(s) entitled
If payment is requested by person(s) entitled, submit FS Form 1522.
If reissue to person(s) entitled is requested, submit FS Form 4000.
If reissue to a trust is requested, submit FS Form 1851.
NOTE: Savings bonds within one month of final maturity cannot be reissued.

For forms, go to
www.treasurydirect.gov.

Other:
PART B – DISTRIBUTION OF SECURITIES
I/We request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)
OR

(Social Security Number)

(Employer Identification Number)

(Address and Telephone Number)

2. Description of securities and/or related payments:
TITLE OF SECURITY

3. Extent of distribution:

ISSUE
DATE

FACE AMOUNT

IDENTIFYING NUMBER

In full
(Amount, Fractional Share, or Percentage)

REGISTRATION

PART B – DISTRIBUTION OF SECURITIES (Continued)
I/We request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)
OR

(Social Security Number)

(Employer Identification Number)

(Address and Telephone Number)

2. Description of securities:
ISSUE
DATE

TITLE OF SECURITY

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

In full

3. Extent of distribution:

(Amount, Fractional Share, or Percentage)

I/We request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)
OR

(Social Security Number)

(Employer Identification Number)

(Address and Telephone Number)

2. Description of securities:
TITLE OF SECURITY

3. Extent of distribution:

ISSUE
DATE

FACE AMOUNT

IDENTIFYING NUMBER

REGISTRATION

In full
(Amount, Fractional Share, or Percentage)

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FS Form 1455

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, and agree to distribution of the securities as indicated in Part B. I/We bind ourselves, our heirs, legatees, successors
and assigns, jointly and severally, to hold the United States harmless on account of the transaction requested, and 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 form, to any party having an ownership or entitlement interest in the securities or payments.
You must wait until you are in the presence of a certifying officer to sign this form.

Sign Here:
(Applicant's Signature)

(Applicant’s Title)

(Number and Street, Rural Route, or PO Box)

(City)

(Daytime Telephone Number)

(State)

(ZIP Code)

(E-Mail Address)

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 is known or
(Name of Person 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 Officer)

(OFFICIAL STAMP
OR SEAL)

(Name of Financial Institution)

(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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FS Form 1455

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

Sign Here:
(Applicant's Signature)

(Applicant’s Title)

(Number and Street, Rural Route, or PO Box)

(City)

(Daytime Telephone Number)

(State)

(ZIP Code)

(E-Mail Address)

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 is known or
(Name of Person 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 Officer)

(OFFICIAL STAMP
OR SEAL)

(Name of Financial Institution)

(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)

INSTRUCTIONS
USE OF FORM – One or more fiduciaries (individual or corporate) must use this form to establish entitlement and request distribution of
United States Treasury Securities and/or related payments to the person lawfully entitled due to termination of a trust, distribution of an
estate, attainment of majority, restoration to competency, or other reason.
If you need more space for any item, use a plain sheet of paper or make photocopies of the relevant section, and attach to the form.
NOTE: For reissue to the estate, use FS Form 4000. For payment to the estate, submit FS Form 1522.
PART A – REASON FOR DISTRIBUTION
Mark a box to show the reason for the distribution. If you mark “Other,” describe the reason, such as attainment of majority or restoration
to competency.
Submit a copy of all evidence that establishes your authority to request this transaction. For example, if you are the
administrator or executor of an estate, provide a certified copy of your letters of appointment, dated within one year of
submission. Submit certified copies of death certificates for all deceased registrants.
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FS Form 1455

PART B – DISTRIBUTION OF SECURITIES
Complete Items 1 through 3.
1.

Enter the name of only one distributee in each Part B, Item 1. (A separate Part B must be completed for each distributee.) Enter the
appropriate Social Security Number or Employer Identification Number.

2.

Describe only the securities and/or checks which the person shown in Item 1 is to receive, in whole or in part:


TITLE OF SECURITY – Identify each security by series, interest rate, type, CUSIP, call and maturity date, as appropriate.
If describing a check, insert the word “check.”



ISSUE DATE – Provide the issue date of each security or check.



FACE AMOUNT – Provide the face amount (par or denomination) of each security or check.



IDENTIFYING NUMBER (if applicable) – Provide the serial number of each security, the confirmation number, or the
check number.



REGISTRATION – Provide the registration of each security, check, or account; also provide the account number, if any.

EXAMPLES:

TITLE OF SECURITY

ISSUE
DATE

FACE AMOUNT

5/15/79

$5,000

Paper Marketable Security

9 1/8 % TREASURY BOND OF
2004-2009 MATURES 5/15/09
CUSIP 912810CG1
Electronic Marketable Security

CUSIP 912795QW4

Electronic Series I Savings Bond

SERIES I

Paper Series EE Savings Bond

SERIES EE

IDENTIFYING NUMBER

REGISTRATION

Serial #

2/5/04

$1,000

1/1/02

$100

7/99

$100

7/26/04

$351.02

JOHN DOE AND JANE DOE
SSN 222-22-2222

123

ACCT # 4800-123-1234
JOHN DOE
SSN 222-22-2222
Confirmation #

12345
Serial #

C-123,456,789-EE

ACCT # N-111-111-111
JOHN DOE
SSN 222-22-2222
JOHN DOE
OR JANE DOE

Check #

Check

CHECK

502123456

JOHN DOE

If unsure what to provide in each of the areas, furnish all identifying information in the space for REGISTRATION.

3.

Mark the box “In full” if the person listed in Item 1 is to receive the entire value of the securities and/or checks described in Item 2. If
the person listed in Item 1 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.

In most cases, we will need additional forms and/or information from the distributee. If so, we may contact the distributee directly. If the
transaction can be processed without additional forms or information from the distributee, we will send the securities and/or payments
directly to the distributee.
Note: If the distributee wants payment of eligible paper securities and the securities are:



Savings bonds or notes, he or she must complete FS Form 1522.
Marketable securities, the fiduciary must complete the assignment on the reverse of the security. The distributee must
complete IRS Form W-9.

Any interest that is or becomes due on securities belonging to the estate of the decedent will be paid to the person to whom the securities
are distributed, unless otherwise requested.

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FS Form 1455

PART C – SIGNATURES AND CERTIFICATIONS
SIGNATURES – The form must be signed in ink. Sign the form in your fiduciary capacity. 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.
CERTIFICATION – Each person whose signature is required must appear before and establish identification to the satisfaction of an
authorized certifying officer. 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:

Acceptable certification for a brokerage:

SIGNATURE GUARANTEED

SIGNATURE GUARANTEED

ABC National Bank

MEDALLION GUARANTEED

Hillview Branch

Generic Brokerage

Authorized Signature

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

ADDITIONAL EVIDENCE – The Commissioner of the Fiscal Service, as designee of the Secretary of the Treasury, reserves the right in
any particular case to require the submission of additional evidence.
WHERE TO SEND – Unless otherwise instructed in accompanying correspondence, send to the appropriate address below:






Series H or Series HH savings bonds – Treasury Retail Securities Site, PO Box 2186, Minneapolis, MN 55480-2186
Definitive (paper) savings bonds – Treasury Retail Securities Site, PO Box 214, Minneapolis, MN 55480-0214
Book-entry savings bonds and marketable securities held in TreasuryDirect – Treasury Retail Securities Site, PO Box 7015,
Minneapolis, MN 55480-7015
Marketable securities held in Legacy Treasury Direct – Treasury Retail Securities Site, PO Box 9150, Minneapolis, MN 554809150
Definitive (paper) marketable securities – Bureau of the Fiscal Service, 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 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 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 Fiscal Service, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form to this
address; send to the appropriate address shown in "WHERE TO SEND" in the Instructions.

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FS Form 1455