Form FS Form 2243 FS Form 2243 SUPPLEMENTAL STATEMENT FOR UNITED STATES SECURITIES

RESET
For Fiscal Service use only:
Customer Name
FS Form 2243
Department of the Treasury
Bureau of the Fiscal Service
(Revised May 2015)

Customer No.

SUPPLEMENTAL STATEMENT FOR
UNITED STATES SECURITIES

OMB No. 1530-0021

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 punishable by fine and/or imprisonment.
PRINT IN INK OR TYPE ALL INFORMATION

NOTE: For Series EE and Series I savings bonds, we no longer issue substitute bonds in paper form. We issue those substitute
bonds in electronic form, in our online system TreasuryDirect. For information on opening an account in TreasuryDirect, go to
www.treasurydirect.gov.

1.

The claim reporting the loss, theft, destruction, or nonreceipt of United States Securities applies to the
securities described in Item 6.

2.

The claim reporting the loss, theft, destruction, or nonreceipt of United States Securities applies to the
securities described in Item 6 rather than the securities described in the original application.

3.

I certify:
I had possession, custody, or control of the securities described in Item 6.
I have firsthand knowledge of the circumstances under which the securities described in Item 6 were
lost, stolen, or destroyed.
I had access to the None Selected

4.

described in Item 6.

I have been informed that

a claim reporting the Select Choice from Drop Down List

submitted
of the United States Securities

(loss, theft, destruction, or nonreceipt)

described in Item 6. My knowledge of the securities is:

5.

If our office has marked this box, please indicate whether you want electronic substitute bonds or payment,
and provide the requested information. NOTE: This applies only to Series EE or Series I savings bonds.
Please issue substitute bond(s) in electronic form into the following TreasuryDirect account.
Account number:
Account name:
Social Security Number or Employer Identification Number:
NOTE: You may add a secondary owner or beneficiary once bonds have been replaced in electronic form
within your TreasuryDirect account. For more information, access your account and click on “How do I” at the
top of the page to find instructions on how to add a secondary owner or beneficiary.
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 Fiscal Service 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.

Please redeem my bonds and make payment to the financial institution below. NOTE: If payment
instructions were previously provided on FS Form 1048, payment will be made according to the instructions
on FS Form 1048.
Payee must provide a Social Security Number or Employer Identification Number:
Social Security Number of Payee

Employer Identification Number of Payee

(Name[s] on the Bank Account)

Type of Account:

Checking

Savings

(Depositor’s Account Number)

Bank Routing Number (nine digits):
(Financial Institution’s Name)

(Financial Institution’s Phone Number)

6. Description of Securities
TITLE OF SECURITY
(Identify securities by series, interest
rate, type, CUSIP, call and maturity
dates, as appropriate)

ISSUE
DATE

FACE AMOUNT
(Denomination)

SERIAL NUMBER

REGISTRATION
(Exactly as shown on the face of each security)

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

7. Signatures and Certification
I/We certify that I/we don't have possession or control of any of the securities described in Item 6 and that I/we don't have any further
information in regard to where they are or what became of them.
I/We severally petition the Secretary of the Treasury for relief as authorized by law and, if relief is granted, acknowledge that the original
securities will become the property of the United States. Upon the granting of relief, I/we assign all our right, title, and interest in the
original securities to the United States and hereby bind myself/ourselves, my/our heirs, executors, administrators, successors and
assigns, jointly and severally: (1) to surrender the original securities to the Department of the Treasury should they come into my/our
possession; (2) to hold the United States harmless on account of any claim by any other parties having, or claiming to have, interests in
these securities; and (3) upon demand by the Department of the Treasury, to indemnify unconditionally the United States and repay to
the Department of the Treasury all sums of money which the Department may pay on account of the redemption of these original
securities, including any interest, administrative costs and penalties, and any other liability or losses incurred as a result of such
redemption.
You must wait until you are in the presence of a certifying officer to sign this form.

Sign Here 
(Signature)

(Print Name)

(Number and Street or Rural Route)

(Social Security Number)

Home Address

(City)

(State)

(ZIP Code)

E-Mail Address

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(Daytime Telephone Number)

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

Sign Here 
(Signature)

(Print Name)

(Number and Street or Rural Route)

(Social Security Number)

Home Address

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

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

Sign Here 
(Signature)

(Print Name)

(Number and Street or Rural Route)

(Social Security Number)

Home Address

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

E-Mail Address
Instructions to Certifying Officer:
1. Name of person who appeared and date of appearance MUST be completed.
2. Medallion stamps require an original signature.
3. Person 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 Number

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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 Number

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 Number

INSTRUCTIONS
PURPOSE OF FORM – Use this form to support an application for relief on account of the loss, theft, destruction, or
nonreceipt of United States Securities.
COMPLETION OF FORM
ITEM 1.

Mark this box to show that the securities described in Item 6 are the missing securities referred to on the
original application. Describe the missing securities in Item 6.

ITEM 2.

Mark this box if incorrect serial numbers were provided on the original application. Describe the correct
missing securities in Item 6.

ITEM 3.

Mark the appropriate box(es) to indicate whether you had possession, custody, or control of the securities,
firsthand knowledge of the circumstances under which they were lost, stolen, or destroyed, or if you had
access to the securities.

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ITEM 4.

Mark this box and complete this item when someone other than the original applicant(s) had custody or
knowledge of the loss. Furnish the name(s) of the original applicant(s) and provide all information
concerning your knowledge of the whereabouts of the securities. If you do not have any knowledge of their
whereabouts, state this. If the original applicant(s) or any other person claims to have mailed or delivered
the securities to you, state whether or not you received them. If you did not receive the securities, explain
why, if known (for example, wrong address used).

ITEM 5.

If our office has marked this box, indicate whether you want electronic substitute bonds or payment. If you
want electronic substitute bonds, provide the requested TreasuryDirect account information. If you want
payment, provide information about your bank. NOTE: If payment instructions were given previously on FS
Form 1048, we will pay according to the instructions on FS Form 1048.

ITEM 6.

Furnish a complete description of the missing securities.

ITEM 7.

If Item 1 or 2 is checked, the form must be signed by the original applicant(s). If Item 3 or 4 is checked, the
form must be signed by the person having custody of the securities or knowledge of their loss. If any
person whose signature is required is a minor who does not have a court-appointed guardian, the minor
may sign on his or her own behalf for Series HH bonds, if in the opinion of the certifying officer, he or she is
of sufficient competency to understand the nature of the transaction. If not, the form must be signed by
both parents on the minor’s behalf. If you have Series EE or Series I bonds, a minor cannot sign on his or
her own behalf. The form must be signed by the parents. If the minor does not reside with either parent,
the form must be completed and signed by the person who furnishes the minor’s chief support. The minor’s
age and Social Security Number must be furnished.
Each person whose signature is required must sign the form in ink, print his or her name, and provide his or
her home address and daytime telephone number. Each signature must be certified.

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 financial institutions, including credit unions, in the United States. For a complete list of such
officers, see Department of the Treasury Circulars, Nos. 300 and 530, and Public Debt Series, Nos. 3-80 and 2-98.
WHERE TO SEND – Send the application and any additional information to the appropriate address:
 HH and H Savings Bonds – Treasury Retail Securities Site, PO Box 2186, Minneapolis, MN 55480-2186
 E, EE, and I Savings Bonds – Treasury Retail Securities Site, PO Box 214, Minneapolis, MN 55480-0214
 Treasury Bills, Notes, Bonds, and TIPS – Department of the Treasury, Bureau of the Fiscal Service, PO Box 426,
Parkersburg, WV 26106-0426
NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
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 05 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 the above address; send to the correct address shown in "WHERE TO SEND"
above.

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