Form FS Form 1022-1 FS Form 1022-1 Report/Application for Relief on Account of Loss, Theft

RESET
For official use only:
Customer Name

Case No.

FS Form 1022-1 (revised June 2018)

OMB No. 1530-0033

Report/Application for Relief on Account
of Loss, Theft, or Destruction of United
States Bearer Securities (Individuals)
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

1. Describe the securities in the spaces below.
TITLE OF SECURITY

SERIAL NUMBER

(Identify by interest rate, title, call and maturity dates)

FACE AMOUNT

DATE ACQUIRED
(mm/dd/yyyy)

(If you need more space to describe your securities, use the continuation sheet on page 3.)

2. Are you the present lawful owner of the securities in your own right? Yes
If you are not the owner, in what capacity are you acting?

No

3. When were the securities acquired?
Provide the name and address from whom the securities were acquired.
(Name)

(Street and Number or Rural Route)

(City)

(State)

(ZIP Code)

4. Were the securities:

•
•

Lost?
Stolen?

Yes
Yes

No
No

Date of theft:

Was a police report filed?

Yes

•
•

Destroyed?

•

Who had the securities last, and why?

•

Who had access to the securities?

•

Where were the securities last placed?

•

When were the securities last seen?

•

Were any identification documents also lost or stolen?

Yes

No

No

If Yes, attach a copy of the report.

(Send any remaining pieces with this form.)

When was the loss discovered?

Yes

No

If Yes, please list them.

•

No
If Yes, please explain fully, and include the name
Have you received reimbursement because of the loss? Yes
and address of the person or firm making reimbursement, the amount of the reimbursement, and the details of any court
proceedings pending or contemplated.

•

What have you done to recover the securities?

•

Tell us the names of any other persons having knowledge of the loss.

FS Form 1022-1

Department of the Treasury | Bureau of the Fiscal Service

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5. If you have been appointed legal representative: (See Item 5 in the Instructions.)

•

What is your legal capacity?

•

Are you court-appointed?

Yes

No

or

6. Taxpayer Identification Number:
(Social Security Number)

(Employer Identification Number)

Under penalty of perjury, I certify that:
1. The above taxpayer identification number is my correct taxpayer identification number (or I am waiting for a number to be issued
to me), and
2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the
Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends,
or (c) I have been notified by the Internal Revenue Service that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien).
(Instructions - You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return.)
SIGNATURE AND CERTIFICATION
I certify that I do not have possession or control of any of the securities described in Item 1 and that I do not have any further
information in regard to where they are or what became of them.
I petition the Secretary of the Treasury for relief as authorized by law, and if such relief is granted, hereby acknowledge that the original
securities shall thereupon become the property of the United States. Upon the granting of relief, I assign all my right, title, and interest
in the original securities to the United States and hereby bind myself, my 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 to 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:

Home Address

(Signature)

(Print Name)

(Number and Street or Rural Route)

(E-Mail Address)

(City)

(State)

(ZIP Code)

(Daytime Telephone 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)

FS Form 1022-1

Department of the Treasury | Bureau of the Fiscal Service

(State)

(ZIP Code)

2

Continuation of description of securities in Item 1:
TITLE OF SECURITY
(Identify by interest rate, title, call and maturity dates)

DATE ACQUIRED
SERIAL NUMBER

FACE AMOUNT

(mm/dd/yyyy)

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

FS Form 1022-1

Department of the Treasury | Bureau of the Fiscal Service

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INSTRUCTIONS
USE OF FORM – Do not use this form for United States Savings Bonds, Retirement Plan Bonds, or Individual Retirement Bonds.
Individuals may use this form to apply for relief on account of loss, theft, or destruction of United States bearer securities or
bearer securities of other agencies or corporations for which the Treasury Department acts as transfer agent. A bond of
indemnity will ordinarily be required, but only on a form that will be provided, when necessary. The Secretary of the Treasury
reserves the right to require additional evidence in any particular case.
COMPLETION OF FORM – Print clearly in ink or type all information requested. If more space is needed for any item, use a
plain sheet of paper and attach it to this form.
ITEM 1.

Describe the securities. Provide as much information as possible.

ITEM 2.

Tell us if you are the owner of the securities, by marking the appropriate box. If you are not the owner, tell us the
capacity in which you are acting. If you have been appointed legal representative, see Item 5 for further
information and/or evidence required to support your application.

ITEM 3.

Tell the exact date that you acquired the securities and show the name and complete address of the person from
whom you acquired them.

ITEM 4.

Check each box that applies. Provide complete details regarding the loss, theft, or destruction of the securities. If
another person had possession of the securities, access to the securities, or knowledge of the circumstances of
the loss, that person must provide a separate statement on FS Form 2243, Supplemental Statement for United
States Securities, explaining the circumstances.

ITEM 5.

If you were appointed as legal representative because:
•

the owner is deceased (with no surviving coowner or beneficiary named on the securities), or

•

the owner or coowner is a minor, or

•

the owner or coowner 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 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.
ITEM 6.

Provide your taxpayer identification number and certify that you are not subject to backup withholding, if
appropriate. If you are subject to backup withholding, you must strike through Item 2 of this section.

SIGNATURE AND CERTIFICATION
• SIGNATURE – Sign the form in ink in the presence of the certifying officer, print your name, and provide your address,
daytime telephone number, and e-mail address, if applicable.
• CERTIFICATION – You 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 complete the certification
form and 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 Circular No. 300, 31 CFR 306.
WHERE TO SEND – Send the completed form, and any additional information or evidence, to Treasury Retail Securities Site,
PO Box 9150, Minneapolis, MN 55480-9150.
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 55 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.

FS Form 1022-1

Department of the Treasury | Bureau of the Fiscal Service

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