FS Form 5179 Security Transfer Request

RESET
FS Form 5179 (revised June 2016)

OMB No. 1530-0042

Legacy Treasury Direct® Security Transfer Request
SEE INSTRUCTIONS -TYPE OR PRINT IN INK ONLY - NO ALTERATIONS OR CORRECTIONS

1. Legacy Treasury Direct ACCOUNT INFORMATION

FOR DEPARTMENT USE

Legacy Treasury Direct ACCOUNT NUMBER:
ACCOUNT NAME

DOCUMENT AUTHORITY
APPROVED BY
DATE APPROVED

2. SECURITIES IDENTIFICATION AND AMOUNT

CHECK THE BOXES WHICH APPLY AND PROVIDE THE INFORMATION REQUESTED.

Transfer ALL my securities for the above Legacy Treasury Direct account.
from the CUSIPs below. (Additional forms are required for more than 10 CUSIPs.)

Transfer my securities totaling $
CUSIP

Department Use
Reference Number

AMOUNT

CUSIP

$

$

$

$

$

$

$

$

Transfer $

Department Use
Reference Number

AMOUNT

of my holdings for CUSIP number

(If you are NOT transferring all of your holdings for this CUSIP, you must also list the specific sub-accounts and amounts to be transferred
below. This information is shown on your Legacy Treasury Direct Statement of Account.)
SUB-ACCOUNT

AMOUNT

SUB-ACCOUNT

$
3. TRANSFER INSTRUCTIONS

AMOUNT

SUB-ACCOUNT

AMOUNT

$

$

CHECK ONE BOX ONLY AND PROVIDE THE INFORMATION REQUESTED FOR THE TRANSFER.

INTERNAL TRANSFER TO ANOTHER Legacy Treasury Direct ACCOUNT NUMBER
NOTE: This must be an existing
account; new accounts aren’t available.

Legacy Treasury Direct ACCOUNT NUMBER
ACCOUNT NAME

Identify the Legacy
Treasury Direct account
to which you want your
securities transferred.

TAXPAYER IDENTIFICATION NUMBER (IF AVAILABLE)
First-Named
Owner

OR
Social Security Number

Employer Identification Number

TRANSFER TO AN ESTABLISHED ONLINE TreasuryDirect ACCOUNT NUMBER
TreasuryDirect ACCOUNT NUMBER

(May be established at www.treasurydirect.gov.)

ACCOUNT NAME
Identify the
TreasuryDirect account to
which you want your
securities transferred.

TAXPAYER IDENTIFICATION NUMBER (IF AVAILABLE)
First-Named
Owner
FS Form 5179

OR
Social Security Number

Employer Identification Number

Department of the Treasury | Bureau of the Fiscal Service

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EXTERNAL TRANSFER TO A FINANCIAL INSTITUTION
NOTE: Failure to provide any of the following information could delay the transfer. See instructions before completing.
ROUTING NUMBER:
FINANCIAL INSTITUTION WIRE NAME:
AGENT or BROKER NAME:

PHONE NO.

AGENT or BROKER ADDRESS:
SPECIAL HANDLING INSTRUCTIONS:

4. AUTHORIZATION

YOU MUST WAIT UNTIL YOU ARE IN THE PRESENCE OF A CERTIFYING OFFICER TO SIGN THIS FORM. IF
THERE ARE TWO OWNERS JOINED BY THE WORD “AND,” BOTH MUST SIGN.

I/We submit this transfer request pursuant to the provisions of Department of the Treasury Circulars, Public Debt Series Nos. 2-86
(31 CFR Part 357) and 1-93 (31 CFR Part 356).
Under penalties of perjury, I/we certify that the information provided on this form is true, correct, and complete.

Signature

Title (if appropriate)

Signature

Title (if appropriate)

Telephone (Daytime)

Mailing Address

5. CERTIFICATION

E-mail Address

YOUR SIGNATURE MUST BE CERTIFIED BY AN AUTHORIZED CERTIFYING OFFICER.

Instructions to Certifying Officer:
1. Name of person(s) who appeared and date/place 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(ies) is/are known or proven to me,
Name(s) of Person(s) Who Appeared

personally appeared before me this

in the year

day of

Year

Month

at

, and signed this request.
City / State

Signature and Title of Certifying Officer

Name of Financial Institution

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.

Address

City / State / ZIP Code

Telephone

Certification by a Notary is NOT Acceptable.
FS Form 5179

Department of the Treasury | Bureau of the Fiscal Service

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INSTRUCTIONS
PURPOSE
You may use this form to request the transfer of securities from a Legacy Treasury Direct account to:
•
another Legacy Treasury Direct account, or
•
an online TreasuryDirect account, or
•
a designated account at a financial institution.
IMPORTANT NOTICES
•
This form must be signed. Only original signatures and forms will be accepted (stamped signatures are not acceptable).
•
Unless all the required information is provided legibly, there may be a delay in processing your request. To avoid delays, read
the instructions carefully and print clearly in ink only.
•
TRANSFER REQUESTS WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS.
1. Legacy Treasury Direct ACCOUNT INFORMATION
Print your Legacy Treasury Direct ACCOUNT NUMBER and the ACCOUNT NAME (registration) as stated on your Legacy Treasury
Direct STATEMENT OF ACCOUNT.
2. SECURITIES IDENTIFICATION AND AMOUNT
Check the boxes which apply and provide the information requested. ALL REQUIRED INFORMATION IS LISTED ON YOUR Legacy
Treasury Direct Statement of Account.
To transfer ALL the securities in the Legacy Treasury Direct account listed in Section 1, check the first box.
To transfer one or more securities in your Legacy Treasury Direct account, check the second box, enter the total dollar amount of the
securities being transferred, and list the CUSIP numbers and amounts.
AMOUNT - The total par for the CUSIP.
CUSIP - The number (for example, 912795XXX) that identifies the securities to be transferred (located under the heading
“Security” on your Statement of Account).
To transfer a portion of one security in your Legacy Treasury Direct account, check the third box, enter only the amount being
transferred, and list the CUSIP number. To transfer security sub-account(s), enter the sub-account number(s) and dollar amount(s) to
be transferred. THE AMOUNT TO BE TRANSFERRED AND THE AMOUNT REMAINING IN THE CUSIP MUST SATISFY BOTH
THE MINIMUM AND MULTIPLE HOLDING REQUIREMENTS FOR THE SECURITY.
3. TRANSFER INSTRUCTIONS
(Choose One Option Only)
INTERNAL TRANSFER TO ANOTHER Legacy Treasury Direct ACCOUNT
Check the box to transfer your securities to another Legacy Treasury Direct account number. The transfer must be to an existing
account; new accounts aren’t available.
•

Legacy Treasury Direct ACCOUNT NUMBER - Enter the number of the account to which the securities are being transferred.

•

ACCOUNT NAME - Enter the ACCOUNT NAME (registration) as shown on the transferee’s Statement of Account.

•

TAXPAYER IDENTIFICATION NUMBER - If available, enter the TAXPAYER IDENTIFICATION NUMBER used on the
account to which the securities are to be transferred.

TRANSFER TO AN ONLINE TreasuryDirect ACCOUNT
Check the box to transfer your securities to an online TreasuryDirect account number.
•

TreasuryDirect ACCOUNT NUMBER - Enter the number of the account to which the securities are being transferred. If a new
account has not yet been established, you can establish one at www.treasurydirect.gov.

•

ACCOUNT NAME - Enter the ACCOUNT NAME (registration) as shown on the online TreasuryDirect account.

•

TAXPAYER IDENTIFICATION NUMBER - If available, enter the TAXPAYER IDENTIFICATION NUMBER used on the
account to which the securities are to be transferred.

EXTERNAL TRANSFER TO A FINANCIAL INSTITUTION
Check the box to transfer your securities to a financial institution for safekeeping or sale. Contact the financial institution for their “BookEntry” delivery instructions. Please note: Securities CANNOT be transferred to a checking or savings account. Provide the
following information:
•

ROUTING NUMBER - ABA (identification) number of the financial institution receiving the securities.

•

FINANCIAL INSTITUTION WIRE NAME - Provide the financial institution’s “Book-Entry” delivery instructions. Instructions
include the receiving bank’s name and safekeeping account number OR the receiving bank’s name and the brokerage firm’s
name (these must be in the approved telegraphic abbreviation “short” form).

•

AGENT/BROKER NAME, PHONE NUMBER, ADDRESS

•

SPECIAL HANDLING INSTRUCTIONS - The customer name and account number at the financial institution for delivery of
securities; any other instructions required by your financial institution.

Examples: To a financial institution for safekeeping:
Routing Number:
Financial Institution Wire Name:
Special Handling Instructions:

XXXXXXXXX
ABC BK/TRUST
FURTHER CREDIT TO JOHN DOE
TRUST ACCOUNT NUMBER XXXXXX

To a financial institution for transfer to a brokerage firm:
Routing Number:
Financial Institution Wire Name:
Special Handling Instructions:

XXXXXXXXX
ABC/CUST/BRKG
FURTHER CREDIT TO JOHN DOE
BROKERAGE ACCOUNT NUMBER XXXXXX

4. AUTHORIZATION
Sign the request in the presence of an authorized certifying officer. Identification may be required. Remember, if there are two owners
joined by the word “and,” both must sign (for example, John Doe and Mary Doe). In case there are questions about this transfer, please
provide a mailing address, daytime telephone number, and, if applicable, e-mail address.
5. CERTIFICATION
Certification of your signature is required. Acceptable certifying officers include authorized employees of insured depository institutions
and corporate central credit unions. Brokers must use a medallion stamp. Certification date and address of financial institution or broker
is required. Please note: Certification by a notary public is NOT acceptable.
Sample certification for a financial institution:

Acceptable certification for a brokerage:

SIGNATURE GUARANTEED
ABC National Bank
Hillview Branch

SIGNATURE GUARANTEED
MEDALLION GUARANTEED
Generic Brokerage

_________________________________
Authorized Signature

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

WHERE TO SEND
If requesting a transfer to another Legacy Treasury Direct account or to a financial institution, mail this form to Treasury Retail
Securities Site, PO Box 9150, Minneapolis, MN 55480-9150.
If requesting a transfer to an online TreasuryDirect account, mail this form to Treasury Retail Securities Site, PO Box 7015,
Minneapolis, MN 55480-7015.
To ensure timely processing, this form must be received at least ten business days in advance of:
• the maturity date of the security
•

an interest payment date for the security

CONTACT
Call us toll-free in the United States at 844-284-2676. Outside the U.S.? Call us at 304-480-6464.
CONFIRMATION OF THE TRANSFER
You will receive a Legacy Treasury Direct Statement of Account after your securities have been transferred. Under certain
circumstances, there may be a hold on the account and a statement won’t be mailed.
NOTICE UNDER THE 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 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 appropriate address shown in “WHERE TO SEND” in the Instructions.

FS Form 5179

Department of the Treasury | Bureau of the Fiscal Service

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