FS Form 5191 Application for Recognition as a Natural Guardian of a M

FS Form 5191
Department of the Treasury
Bureau of the Fiscal Service
(Revised September 2015)

OMB No. 1530-0042

Legacy Treasury Direct®

APPLICATION FOR RECOGNITION AS
NATURAL GUARDIAN OF A MINOR

www.treasurydirect.gov
844-284-2676 (toll free)

Visit us on the Web at 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 under the laws of the United States.
TYPE OR PRINT IN INK ONLY - APPLICATIONS WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS

1. Legacy Treasury Direct ACCOUNT INFORMATION

FOR DEPARTMENT USE

ACCOUNT NUMBER(S):
DOCUMENT AUTHORITY

APPROVED BY

DATE APPROVED

2. MINOR
NAME:
MINOR’S TAXPAYER IDENTIFICATION NUMBER:
DATE OF BIRTH:
3. GUARDIAN
NAME:
ADDRESS:
TELEPHONE: (

)

RELATIONSHIP TO MINOR:

PARENT

FURNISH CHIEF SUPPORT

OTHER (specify)

MARRIED? If your spouse did not apply as natural guardian with you, please have your spouse sign after the following statement:
I consent to the above-named parent acting as the guardian for our minor child.

Signature

SEPARATED OR DIVORCED? You must furnish a certified copy of court records showing you have custody of the minor.

NAMES AND ADDRESSES OF OTHERS WHO REGULARLY CONTRIBUTE TO THE MINOR’S SUPPORT, AND THE
PERCENTAGE OF THEIR CONTRIBUTIONS:

DOES THE MINOR RESIDE WITH YOU?

YES

NO

IF NO, PROVIDE THE NAME AND ADDRESS OF THE PERSON WITH WHOM THE MINOR RESIDES:

SEE INSTRUCTIONS FOR PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE

RESET

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 REQUEST THAT I BE RECOGNIZED AS NATURAL GUARDIAN OF THE SAID MINOR FOR PURPOSES OF FURNISHING THE
PAYMENT INSTRUCTIONS FOR THE ACCOUNTS LISTED AND TO EXECUTE ANY NECESSARY TRANSACTION REQUESTS
FOR THOSE ACCOUNTS.

I CERTIFY THAT NO LEGAL GUARDIAN OR SIMILAR REPRESENTATIVE HAS BEEN APPOINTED FOR THE SAID MINOR AND
NO SUCH APPLICATION IS CONTEMPLATED AND THAT THE SAID MINOR HAS AN INTEREST IN WHOLE OR IN PART IN
SECURITIES HELD IN THE ACCOUNTS LISTED.

IN CONSIDERATION FOR MY RECOGNITION AS NATURAL GUARDIAN OF THE MINOR, I HEREBY AGREE THAT I WILL
PROMPTLY NOTIFY THE BUREAU OF THE FISCAL SERVICE IF (A) THE MINOR’S DISABILITY IS REMOVED UNDER THE
LAWS OF THE STATE OF HIS OR HER RESIDENCE, (B) A LEGAL GUARDIAN OR SIMILAR REPRESENTATIVE IS APPOINTED
FOR THE MINOR’S ESTATE, (C) I NO LONGER FURNISH CHIEF SUPPORT FOR THE MINOR (WHEN SUPPORT IS THE BASIS
FOR RECOGNITION), OR (D) THE MINOR DIES.

SIGNATURE(S)

5. CERTIFICATION

The natural guardian’s signature MUST be certified by an authorized certifying officer.

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(IES) IS/ARE
NAME(S) OF PERSON(S) WHO APPEARED

KNOWN OR PROVEN TO ME, PERSONALLY APPEARED BEFORE ME THIS
AT
CITY/STATE

ACCEPTABLE CERTIFICATIONS:

DAY OF

MONTH/YEAR

AND SIGNED THIS APPLICATION.

SIGNATURE AND TITLE OF CERTIFYING OFFICER

Financial Institution’s Official Seal or
Stamp (Such as Corporate Seal, Signature
Guaranteed Stamp or Medallion Stamp).
Brokers must use a Medallion Stamp.

NAME OF FINANCIAL INSTITUTION

ADDRESS

CITY/STATE/ZIP CODE

TELEPHONE

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FS Form 5191

FS Form 5191
Department of the Treasury
Bureau of the Fiscal Service
(Revised September 2015)

INSTRUCTIONS FOR COMPLETING AN
APPLICATION FOR RECOGNITION AS
NATURAL GUARDIAN OF A MINOR

www.treasurydirect.gov
844-284-2676 (toll free)

PURPOSE
This form can be used to:
• apply for recognition as a natural guardian of a minor who owns, wholly or in part, Legacy Treasury Direct securities in an
estate where a legal representative has not been appointed.
• apply for recognition as a natural guardian when a designated natural guardian is no longer acting. (A death certificate,
physician’s certificate, or certified evidence of court action must be submitted as proof of the designated natural guardian’s inability to act.)
IMPORTANT NOTE
• 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 this form. To avoid delays, read
the instructions carefully and type or print clearly in ink only.
• This form MUST be signed in all cases.
• APPLICATIONS WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS.
WHO MAY APPLY
The parent with whom the minor resides may apply. If the minor resides with both parents, either or both may apply. The
parent who has not joined in the application should consent by signing the statement within the box
in Section 3. If the parents are separated or divorced, no consent is required provided that a certified copy of court records is
furnished showing that the parent applying has custody. If the minor does not reside with either parent, the person who
furnishes the minor’s chief support may apply.
No application will be considered if the Department of the Treasury is on notice that 1) the minor’s disability no longer exists
under the laws of the state of his or her residence, 2) a legal guardian or similar representative of the minor’s estate had been
appointed, 3) the applicant is not entitled to act as natural guardian, or 4) the minor has died.
1. Legacy Treasury Direct ACCOUNT INFORMATION
Provide the ACCOUNT NUMBER(S) of all Legacy Treasury Direct accounts owned wholly or in part by the minor.
2. MINOR
Provide the minor’s NAME, TAXPAYER IDENTIFICATION NUMBER, and DATE OF BIRTH.
3. GUARDIAN
Provide your NAME and ADDRESS, and indicate your relationship to the minor. Remember: If you are married and your spouse
did not apply as natural guardian with you, please have your spouse sign the statement within the box. If you’re separated
or divorced, furnish a certified copy of court records showing you have custody of the minor.
If you are applying as the furnisher of chief support for the minor, provide the names and addresses of others who regularly
contribute to the minor’s support and the extent of their contributions (expressed as a percentage of the minor’s total support).
Indicate whether the minor resides with you. If not, provide the name and addresses of the person with whom the minor resides.

4. AUTHORIZATION
Read the authorization statement carefully. In the presence of an authorized certifying officer, sign the form in ink.
5. CERTIFICATION
Certification of your signature is required. Acceptable certifying officers include authorized employees of insured depository
institutions and corporate central credit unions. Certification date, address, and telephone number of the financial institution
are required.

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FS Form 5191

WHERE TO SEND
Completed forms must be submitted to:

Treasury Retail Securities Site
PO Box 9150
Minneapolis, MN 55480-9150

This form should be submitted in support of a specific transaction request. Subsequent requests should be accompanied by
additional natural guardian applications forms.
Contact
Call us toll-free in the United States at 844-284-2676. Outside the U.S.? Call us at 304-480-6464.

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
Fiscal Service 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
Fiscal Service; 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; instead, submit completed form to the address shown in “WHERE TO SEND” in the
Instructions.

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FS Form 5191