Form FS Form 2966 FS Form 2966 Special Bond of Indemnity by Purchaser of United States

RESET
For official use only:
Customer Name

Case Number

FS Form 2966
Department of the Treasury
Bureau of the Fiscal Service
(Revised February 2016)

SPECIAL BOND OF INDEMNITY BY PURCHASER OF UNITED STATES
SAVINGS BONDS/NOTES INVOLVED IN A CHAIN LETTER SCHEME

OMB No. 1530-0030

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

KNOW ALL MEN BY THESE PRESENTS, that I,

of
(Name)

in

(Street Address)

, am held and firmly bound to the United States of America in the
(City and State)

(ZIP Code)

amount of

($

)

(For Series E and Series I, show seven times the face amount of the bonds listed below;
for Series EE, show four times the face amount.)
to be paid to the United States of America; to which payment I bind myself, my heirs, legatees, executors, administrators,
successors and assigns, jointly and severally, by this agreement.
WHEREAS, I present and surrender the following-described United States Savings Bonds to the United States
Department of the Treasury:
FACE
AMOUNT

ISSUE DATE

BOND NUMBER

INSCRIPTION
(Provide Social Security Number, names, including middle names or initials, and
addresses on the bonds.)

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

AND WHEREAS, I allege under penalty of perjury that I purchased these bonds with my funds with the intention of participating in
a chain letter scheme, and I later discovered that participation in such a scheme violates certain laws and regulations of the United
States if the mails were used and might violate state laws even if the mails were not used;
AND WHEREAS, under these circumstances, I do not wish to participate in the scheme and hereby request that the United
States REFUND THE PURCHASE PRICE of these bonds;
AND WHEREAS, the Secretary of the Treasury has authorized the REFUND OF THE PURCHASE PRICE of these bonds, if I
furnish satisfactory evidence that I am the purchaser of the bonds, and if I furnish a bond of indemnity without surety to the United
States of America in the above amount;
NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, that if I, my heirs, legatees, executors, administrators,
successors or assigns, or any of them, will indemnify and save harmless the United States from any claim on account of these bonds
and interest thereon, and from any and all losses which the United States may sustain as a result of any such other claim, and shall
repay to the United States all sums of money which the United States may pay on the account of these bonds and interest thereon,
with interest, administrative costs, and penalties, then this obligation will be void, otherwise it will remain in full force and effect.

DELIVERY INSTRUCTIONS: Please deposit my funds directly, as authorized below.
(Name or Names on the Bank Account)

(Bank Routing No.)

Type of Account:

Checking

(Bank Name)

Savings

(Bank Account Number)

(Bank Phone)

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

Sign Here
(Signature of obligor--must agree with name in first paragraph)

(Print Name)

Mailing Address

(Social Security Number)

(E-mail Address)

(Daytime Phone Number)

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

I CERTIFY that

, whose identity is known or

was 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)

(Number and Street or Rural Route)
(City)

(State)

(ZIP Code)

INSTRUCTIONS
("Bonds" below refers to savings bonds, savings notes, retirement plan bonds, and individual retirement bonds.)
USE OF FORM – Use this form to apply for refund of purchase price of United States Savings Bonds purchased in
connection with a chain letter scheme.
 Furnish your full name including first name, middle name or initial, and last name.
 Enter the amount of the bond of indemnity, in alphabetical and numerical form. The amount necessary depends on
the type of bond involved. Series EE, Series E, and Series I bonds may earn interest beyond their original maturity
date. As a result, the bond of indemnity must be in an amount four times the face amount of the Series EE bonds
and seven times the face amount of the Series E and Series I bonds listed on the form. For example, for a $50
Series EE bond, the amount must be shown as "TWO HUNDRED DOLLARS" ($200.00) and for a $50 Series E or
Series I bond, the amount must be shown as "THREE HUNDRED FIFTY DOLLARS" ($350.00).
 Provide instructions for direct deposit into your bank account.
 Sign the form. (See the next section regarding proper certification.)
CERTIFICATION – Person Who Signs Form: You must appear before and establish identification to the satisfaction of
an authorized certifying officer and sign in the presence of that officer. These 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, No. 530, and Public Debt Series Nos. 3-80 and 2-98. Certifying Officer: The person appearing before you
must establish identification by positive and reliable evidence before this form is signed, unless he or she is personally
known to you. You must complete and sign the certification form and affix the seal or stamp required in certifying
requests for payment.
ADDITIONAL EVIDENCE – You must provide evidence that you purchased the bonds. Such evidence includes a copy of
the purchase order; a statement from the issuing agent that accepted the order; the canceled check used to purchase the
bond; or a copy of the chain letter bearing your name. If the evidence shows that someone else was the purchaser of the
bonds and you obtained possession from that person, you will also be expected to furnish a notarized statement from the
original purchaser to establish the circumstances under which he or she delivered the bonds.
WHERE TO SEND – Send the FS Form 2966, bonds, proof of purchase, and any other appropriate evidence, to Treasury
Retail Securities Site, P.O. Box 214, Minneapolis, MN 55480-0214.
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
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 08 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 in "WHERE TO
SEND.”

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