Form FS Form 4094 FS Form 4094 Affidavit By Individual Surety

OMB No. 1530-0047

FS Form 4094
Department of the Treasury
Bureau of the Fiscal Service
(Revised August 2015)

AFFIDAVIT BY INDIVIDUAL SURETY

This form is attached to and forms part of the Bond of Indemnity executed by:
SURETY I
STATE OF

COUNTY OF

I,

, BEING DULY SWORN, DEPOSE AND SAY: I'm one of the

sureties in the foregoing bond; I'm a citizen or resident of the United States; and I'm of full age and legally competent.
My legal residence is:

,

,

(Number and Street or Rural Route)

(City)

,
(County)

,

.

(State)

(ZIP Code)

I am the sole owner in fee simple of the real estate located at:
,

,

(Number and Street or Rural Route)

(City)

,
(County)

,

; AND

(State)

(ZIP Code)

 the fair valuation of said real estate is $
;
 the assessed value of said real estate for taxation purposes is $
;
 the real estate is not exempt from seizure and sale under any homestead, community, or marriage law, or upon
any attachment, execution, or judicial process.
The real estate is not encumbered by any mortgage, delinquent taxes, or other lien except as follows:
$

.
(Amount)

(Nature of Encumbrances)

In addition to the said real estate, I own personal property subject to execution and sale as described below, in the
amount of $
, over and above my just debts and liabilities:
(Describe Personal Property Fully)

I'm worth in real estate and personal property together the sum of $
, over and above
(1) all my debts and liabilities, owing and incurred;
(2) any property exempt from execution;
(3) the aggregate full penalties on all other bonds on which I am principal or surety;
(4) any pecuniary interest I have in the business of the principal on the said bond; and
(5) any interest I have in any property, real or personal, held in community, in joint ownership, or in tenancy by the
entirety; and
I am
.
(Married or Unmarried)
SIGN HERE X
(Surety's Signature)
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 affidavit.

at
(City)

(State)
(Signature and title of certifying officer)

(OFFICIAL STAMP
OR SEAL)

(Street address)
(City)

(State)

(ZIP Code)

RESET

SURETY II

STATE OF

COUNTY OF

I,

, BEING DULY SWORN, DEPOSE AND SAY: I'm one of the

sureties in the foregoing bond; I'm a citizen or resident of the United States; and I'm of full age and legally competent.
My legal residence is:

,

,

(Number and Street or Rural Route)

(City)

,
(County)

,

.

(State)

(ZIP Code)

I am the sole owner in fee simple of the real estate located at:
,

,

(Number and Street or Rural Route)

(City)

,
(County)

,

; AND

(State)

(ZIP Code)

 the fair valuation of said real estate is $
;
 the assessed value of said real estate for taxation purposes is $
;
 the real estate is not exempt from seizure and sale under any homestead, community, or marriage law, or upon
any attachment, execution, or judicial process.
The real estate is not encumbered by any mortgage, delinquent taxes, or other lien except as follows:
$

.
(Amount)

(Nature of Encumbrances)

In addition to the said real estate, I own personal property subject to execution and sale as described below, in the
amount of $
, over and above my just debts and liabilities:
(Describe Personal Property Fully)

I'm worth in real estate and personal property together the sum of $
, over and above
(1) all my debts and liabilities, owing and incurred;
(2) any property exempt from execution;
(3) the aggregate full penalties on all other bonds on which I am principal or surety;
(4) any pecuniary interest I have in the business of the principal on the said bond; and
(5) any interest I have in any property, real or personal, held in community, in joint ownership, or in tenancy by the
entirety; and
I am
.
(Married or Unmarried)
SIGN HERE X
(Surety's Signature)
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 affidavit.

at
(City)

(State)
(Signature and title of certifying officer)

(OFFICIAL STAMP
OR SEAL)

(Street address)
(City)

(State)

(ZIP Code)

CERTIFICATE OF SUFFICIENCY

I hereby certify that
and
, the sureties
named on the FS Form 4094, are personally known to me, that, in my judgment, each is responsible, and qualified to act
as such, and that, to the best of my knowledge and belief, the facts stated by each in his/her affidavit are true.

This certificate must be executed: by an officer of
a Federal Reserve Bank or Branch, or of an
incorporated bank or trust company, or of a
Federal Savings and Loan Association, or other
organization which is a member of the Federal
Home Loan Bank System but in the latter case
only for a regular customer; or by a judge or clerk
of a Federal or State court of record; or by a
United States district attorney, commissioner,
marshal, or director of internal revenue or
collector of customs. The corporate, official, or
court seal, as appropriate, must be impressed,
but if the certifying officer has no seal, that fact
must be shown and attested. (A notary public is
NOT an acceptable certifying officer.)

(SEAL)

(Signature and official designation of Certifying Officer)

(Name of Bank, Trust Company, Association or Organization, if applicable)

Dated at
on

,
(Month and Day)

(Year)

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 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 address shown in the
accompanying correspondence.