Form FS Form 2001 FS Form 2001 Release

For Fiscal Service use only:
Customer Name	     	Customer No.	     

FS Form 2001 Department of the Treasury Bureau of the Fiscal Service (Revised April 2015)	RELEASE	OMB No. 1530-0053 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 that is punishable by fine and/or imprisonment. PRINT IN INK OR TYPE ALL INFORMATION

I,	     	, am the registered owner, coowner, or other
person entitled or authorized to request payment of the following-described United States securities.

ISSUE DATE	FACE AMOUNT	BOND NUMBER or CONFIRMATION NUMBER	REGISTRATION (Provide complete Social Security Number [for example,123-45-6789] and names, including middle names or initials, on the securities)
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     

DOUBLE-CLICK HERE FOR A CONTINUATION SHEET  

The proceeds of these securities were sent to the bank listed on Legacy Treasury Direct or TreasuryDirect Account No.

     

on

     

.

(Date)

The proceeds of these bonds were paid to

     

upon a request signed in the

name of

     

on

     

.

(Date)

I desire to waive any claim I might have to the of the above-described securities or the issue of new securities in lieu thereof, and I therefore ratify the of said securities to the same extent as though the had been made me. I authorize , and hereby release, exonerate, and discharge the United States of America from any and all liability to me on account of the .

SIGNATURES AND CERTIFICATIONS Under penalties of perjury, I/we certify that the information provided on this form is true, correct, and complete. This request is submitted pursuant to the applicable provisions of 31 CFR Parts 315, 353, 356, 357, 360, and 363. I agree to indemnify and hold the United States harmless in the event of any loss that results from this request.

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

Sign Here

     

(Signature)

(Print Name)

Mailing Address

     

     

(Number and Street or Rural Route)

(Social Security Number)

     

     

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

E-Mail Address

     

Instructions to Certifying Individual: Name of person(s) who appeared and date of appearance MUST be completed. Medallion stamps require an original signature. Person(s) must sign in your presence.

I CERTIFY that

, whose identity is

(Name of Person Who Appeared)

known or proven to me, personally appeared before me this

day of

(Month/Year) (Year)

at

, and signed this form.

(City/State)

(Signature and Title of Certifying Individual)

(OFFICIAL STAMP

OR SEAL)

(Name of Financial Institution)

(Address)

Acceptable Certifications: Financial Institution's Official Seal or Stamp (such as Corporate Seal,

(City/State/ZIP Code)

Signature Guaranteed Stamp, or Medallion Stamp). Brokers must use a Medallion Stamp.

(Telephone)

IDENTIFICATION NOTATIONS

Customer Account Number and Date Established:

Documents - Description:

Identified by (Signature and Address):

INSTRUCTIONS

USE OF FORM

The registered owner, coowner, or other person entitled to the United States securities must use this form to ratify payment of the security(ies), if the Department's investigation discloses that payment of the security(ies) was made to an unauthorized person.

WHO SHOULD SIGN

The registered owner or coowners of the security(ies) must sign this form. If the registered owner is deceased, or is a minor or incompetent, each person entitled to the security(ies) or to an interest therein, or authorized to request payment, must sign.

CERTIFICATION

Person who signs form

You must appear before and establish identification to the satisfaction of an authorized certifying officer and sign the request in the presence of the officer. 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 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 place an adequate notation on page 2, or on a separate record, showing exactly how identification was established. A notation is adequate if it is sufficiently detailed to permit, at a later date, a determination of the exact identification actually used. Complete and sign the certification form and affix the seal or stamp required in certifying requests for payment.

WHERE TO SEND

Unless otherwise instructed in accompanying correspondence, send the completed form, the securities (if appropriate), and any other necessary evidence to the appropriate address:

• Definitive (paper) savings bonds: Treasury Retail Securities Site, PO Box 214, Minneapolis, MN 55480-0214

• Electronic securities: Department of the Treasury, Bureau of the Fiscal Service, PO Box 733, Parkersburg, WV 26106-0733

PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICES

We're asking for the information on this form to assist us in processing your securities transaction requests. Our authority comes from 31 U.S.C. Ch. 31 which authorizes the Treasury Department to borrow money to pay the public debt of the United States. Also, 26 U.S.C. 6109 requires us to use your SSN on certain forms when we report taxable income to IRS. It's voluntary that you provide the requested information, but without it, we may not be able to process your transaction requests. Information concerning your securities holdings and transactions is considered confidential under Treasury regulations (31 CFR Part 323) and the Privacy Act. However, the following routine uses of this information may include disclosure to the following persons or entities: agents and contractors who help us manage the public debt; others entitled to the securities or payment; agencies (including disclosure through approved computer matches) determining eligibility for benefits, finding persons we've lost contact with, or helping us collect debts; agencies for investigations or prosecutions; courts, counsel, and others for litigation and other proceedings; a Congressional office asking on your behalf; and as otherwise authorized by law.

We estimate it will take you about 06 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 address shown in "WHERE TO SEND" above.

(SEE INSTRUCTIONS ON PAGE 3)