Form FS Form 3062-4 FS Form 3062-4 Claim for United States Savings Bonds Not Received

RESET
For official use only:
Customer Name

Customer No.

FS Form 3062-4
Department of the Treasury
Bureau of the Fiscal Service
(Revised July 2015)

CLAIM FOR UNITED STATES SAVINGS BONDS NOT RECEIVED

OMB No. 1530-0048

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

I/We, the undersigned, certify that the United States Savings Bonds described on this form have not been received, either by
me/us, or by anyone on my/our behalf. If the addressee has moved since the bonds were mailed, I/we also certify that an
inquiry was made at the former address.

1. DESCRIPTION OF BONDS – Describe the missing bonds in the spaces below. If you don’t know the bond serial numbers,
provide all of the information requested below and also indicate the total number of bonds that are missing.
ISSUE DATE
(Give specific month and year
of purchase.)

FACE AMOUNT

BOND NUMBER

INSCRIPTION
(Provide complete Social Security Number [for example, 123-456789], names, including middle names or initials, and addresses
[street, city, state] on the bonds.)

(If you need more space to describe your bonds, use a continuation sheet and attach it to this form.)

2. DETAILS OF THE PURCHASE – Provide all requested information.

•

Who purchased the bonds?
(Purchaser's Name)
(Purchaser's Social Security Number)

3. AUTHORITY – Provide details regarding your authority to complete a claim for the bonds.

•

Yes

Are you named on the bonds?

No If Yes, skip to Item 4. If No, provide the following information:

Describe your authority:
(parent, guardian, conservator, legal representative, administrator, executor, purchaser, etc.)

Yes

Are you court appointed?

No (If Yes, see "LEGAL REPRESENTATIVE" in the Instructions.)

4. MINORS – Provide details regarding any minor named on the bonds. (See "MINORS" in the Instructions.)

•

Is there a minor named on the bonds?

•

What is the minor's :
•

•

Yes

No If No, skip to Item 5. If Yes, fully complete the following:

Name?
• Social Security Number?

DOB?

•

What is your relationship to the minor?

•

Does the minor live with you?

Yes

No

If No, with whom?
(Name)

(Relationship to Minor)
(Address)

•

Who provides the minor's chief support?
(Name)

(Relationship to Minor)
(Address)

•

Are both parents able to sign the application for relief?
Yes
If Yes, skip to Item 5. If No, fully complete the following:
•

Why are you unable to obtain the signature?

•

Could that parent have possession of the bonds?

1

No

Yes

No

FS Form 3062-4

5. RELIEF REQUESTED – Indicate whether you want substitute bonds or payment.
NOTE: Payment can't be made for Series EE or Series I bonds dated February 2003 and later until such bonds are one year past
their issue date. Also, substitute bonds can’t be issued in some cases, including if a bond is within one full calendar month of its
final maturity. See Item 5 in Instructions.

A. Series EE or Series I Bonds
• I/We hereby request:

*Substitute Electronic Bonds

Payment by Direct Deposit

*If you choose substitute electronic bonds and don’t have a TreasuryDirect
account, don’t open an account; we will contact you and give you instructions;
also, skip Item 6 below.
B. Series HH Bonds
• I/We hereby request:

Substitute Paper Bonds

Payment by Direct Deposit

6. DELIVERY INSTRUCTIONS

A. FOR ELECTRONIC SUBSTITUTE BONDS—SERIES EE OR SERIES I
TreasuryDirect account number is:
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 firstnamed coowner will be considered the principal coowner for the purpose of this transaction.

B. FOR SUBSTITUTE PAPER BONDS—SERIES HH
MAIL BONDS TO:
(Name)
(Number and Street, Rural Route and Box, or PO Box)

(City)

(State)

(ZIP Code)

C. FOR DIRECT-DEPOSIT PAYMENT—ANY SERIES OF BONDS
NOTE: Payment can’t be made for Series EE or Series I bonds dated February 2003 and later until such bonds are one year
past their issue date. Also, substitute bonds can’t be issued in some cases, including if a bond is within one full calendar month
of its final maturity. See Item 5 in Instructions.

Payee must provide a Social Security Number or Employer Identification Number:
(Employer Identification Number of Payee)

(Social Security Number of Payee)

(Name[s] on the Account)

Type of Account:

Checking

Savings

(Depositor's Account No.)

Bank Routing No. (nine digits):

(Financial Institution's Name)

(Financial Institution’s Phone No.)
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FS Form 3062-4

7. SIGNATURES AND CERTIFICATION
I/We severally petition the Secretary of the Treasury for relief as authorized by law and, if relief is granted, acknowledge that the original bonds
become the property of the United States. Upon the granting of relief, I/we assign all our right, title, and interest in the original bonds to the
United States and bind myself/ourselves, my/our heirs, executors, administrators, successors and assigns, jointly and severally: (1) to surrender
the original bonds to the Department of the Treasury if they are recovered; (2) to hold the United States harmless due to any claim by any other
parties having, or claiming to have, interests in these bonds; 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 due to the
redemption of these original bonds, including any interest, administrative costs and penalties, and any other liability or losses incurred as a result
of such redemption. I/We consent to the release of any information in this form or regarding the bonds described to any party having an
ownership or entitlement interest in these bonds.
I/We certify, under penalty of perjury, and severally affirm and say that the bonds described on this form were never received, and that the
information given is true to the best of my/our knowledge and belief.

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 and Box)

(Social Security Number)

Home Address

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

E-Mail Address
Sign Here ⇒
(Signature)

(Print Name)

(Number and Street or Rural Route and Box)

(Social Security Number)

Home Address

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

E-Mail Address
Sign Here ⇒
(Signature)

(Print Name)

(Number and Street or Rural Route and Box)

(Social Security Number)

Home Address

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

E-Mail Address

3

FS Form 3062-4

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. NOTE: To certify more than two signatures, use the next page too.

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)

at

and signed this form.
(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)

(Notary certification is NOT acceptable.)

(Telephone)

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)

at

and signed this form.
(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)

(Notary certification is NOT acceptable.)

(Telephone)

4

FS Form 3062-4

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)

at

and signed this form.
(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)

(Notary certification is NOT acceptable.)

(Telephone)

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 requried 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.

INSTRUCTIONS
PURPOSE OF FORM – Use this form to apply for relief on account of the nonreceipt of United States Savings Bonds.
WHO MAY APPLY – This form must be completed and signed by all persons named on the bonds, or by an authorized
representative.
ATTACHMENTS – If more space is needed for any item, use a plain sheet of paper and attach it to the form.
PROOF OF DEATH – If a registrant is deceased, a certified copy of his or her official death certificate must be submitted with
this form.
LEGAL REPRESENTATIVE – If you were appointed as legal representative because:
•
•
•

the owner is deceased (with no surviving co-owner or beneficiary named on the bonds), or
the owner or co-owner is a minor, or
the owner or co-owner is incapacitated,

complete the form and submit a court certificate or certified copy of your letters of appointment, under court seal, showing the
appointment is still in full force. If your name and official capacity are shown in the registration of the bonds, evidence of your
appointment is not necessary.
If no legal representative has been appointed for a deceased or incompetent owner, advise the Bureau of the Fiscal Service and
additional instructions will be provided.
MINORS – A minor (who does not have a court-appointed guardian) who is requesting payment or who is named on Series HH
bonds may complete and sign the form on his or her own behalf if, in the opinion of the certifying officer, he or she is of sufficient
competency and understanding to comprehend the nature of the transaction. If, in the opinion of the certifying officer, the minor
is not of sufficient competency and understanding or is requesting electronic substitute bonds for Series EE or Series I, the
parents must sign on behalf of the minor. If the minor does not reside with either parent, the form must be completed and
signed by the individual who furnishes the minor’s chief support.
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FS Form 3062-4

COMPLETION OF FORM – Print clearly in ink or type all information requested.
ITEM 1. Describe the missing bonds by bond serial number. If you don't know the bond serial numbers, you must provide
the specific month and year of purchase, and the Social Security Number, name (including middle name or initial),
and complete address (street, city, state) that appear on the bonds. Also state the total number of missing bonds.
ITEM 2. Provide the requested information regarding the purchase of the bonds.
ITEM 3. Provide details regarding your authority to complete a claim for the missing bonds.
appointed, see "LEGAL REPRESENTATIVE" above.

If you have been court

ITEM 4. Complete this item if a minor is named on the bonds and he or she is not of sufficient competency and
understanding to complete the form on his or her own behalf. Provide the minor’s name, date of birth, Social
Security Number, and all other requested information. See "MINORS" above for more information.
ITEM 5. Indicate whether you want substitute bonds or payment by direct deposit.
NOTES: 1) Series EE and Series I bonds issued February 2003 and later are not eligible for payment until one full
year after issue. 2) If you ask for substitute bonds and the bonds are within one full calendar month of reaching final
maturity, we will make payment instead. 3) For Series EE and Series I bonds, we no longer issue substitute bonds
in paper form. We issue those substitute bonds in electronic form, in our online system TreasuryDirect. 4) If you
want substitute Series EE bonds or substitute Series I bonds and you don’t have a TreasuryDirect account, don’t
open an account; we will contact you and give you instructions. (For information on TreasuryDirect, go to
www.treasurydirect.gov.)
ITEM 6. Complete either section A, B, or C. Which section is appropriate for you depends on which series of bonds you have
and whether you want payment or electronic substitute bonds.
ITEM 7. Each person whose signature is required must sign the form in ink, print his/her name, and provide his/her home
address, Social Security Number, daytime telephone number, and, if applicable, e-mail address. Each signature
must be certified (see "CERTIFICATION" below).
CERTIFICATION – Each person whose signature is required must appear before and establish identification to the satisfaction
of an authorized certifying officer and sign the form 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 banking 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 this form and any additional information to Treasury Retail Securities Site, PO Box 214, Minneapolis,
MN 55480-0214.
For Bond-Related Inquiries:
•
•
•
•

Email:
Phone:
Fax:
Mail:

[email protected]
844-284-2676 (toll free)
612-629-4285
Treasury Retail Securities Site, PO Box 214, Minneapolis, MN 55480-0214

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FS Form 3062-4