FS Form 5178 Transaction Request

RESET

For official use only:

Customer No

Case or SR#

Customer Name

FS Form 5178 (Revised May 2019)

OMB No. 1530-0042

Legacy Treasury Direct®

Transaction Request
IMPORTANT: Follow instructions in filling out this form. Making any false, fictitious, or fraudulent claim or statement to the United States is a crime and
may be prosecuted. Print in ink or type all information. This form will not be accepted if it has any alterations or corrections.

1. LEGACY TREASURY DIRECT ACCOUNT INFORMATION
Legacy Treasury Direct ACCOUNT NUMBER: ____________________________________
ACCOUNT NAME: __________________________________________________________________________________
__________________________________________________________________________________________________
2. TRANSACTION REQUESTED – Check the box next to the transaction(s) you are requesting.
Consolidation of Legacy Treasury Direct Accounts – For identical accounts only.
Legacy Treasury Direct Account Numbers to be closed:

__________________________________
__________________________________
__________________________________
__________________________________

Surviving Legacy Treasury Direct Account Number:

__________________________________

Name change – Provide the complete account name as it should appear (see items 2 & 3 in the instructions).
This type of change usually requires a certified signature.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Address change – Provide the complete address as it should appear.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Telephone number change – Provide each complete number, including extension, if applicable:
_____________________________________

_____________________________________

(Daytime Telephone Number)

(Alternate Telephone Number)

Payment information change – Provide the complete direct deposit information as it should appear. This
change requires a certified signature (see items 2 & 3 in the instructions).
Bank Routing No. (nine digits): _______________________________
_________________________________________

Type of Account

Checking

Savings

(Depositor’s Account No.)

___________________________________________________

______________________________

(Financial Institution’s Name)

(Financial Institution’s Phone No.)

Taxpayer Identification Number correction – Use only for a correction. Provide the correct number:
_____________________________________
(First-Named Owner’s Social Security Number)

FS Form 5178

or

_____________________________________
(Owner’s Employer Identification Number)

Department of the Treasury | Bureau of the Fiscal Service

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3. SIGNATURES AND CERTIFICATION
Under penalties of perjury, I/we certify that the information provided on this form is true, correct, and complete. I certify that I have the
authority to authorize financial transactions using the bank information described on this form. I agree to indemnify and hold the United
States harmless in the event of any loss that results from this request.
For Taxpayer Identification Number corrections, I certify under penalty of perjury that:
1. The Taxpayer Identification Number shown on this form is my correct Taxpayer Identification Number, 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).
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.
The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup
withholding.
Sign in ink in the presence of a certifying officer and provide the requested information.
If there are two owners joined by the word "and," both may have to sign (see the instructions).

Sign
Here: __________________________________________________________________________________________________
(Signature)
_____________________________________________________

______________________________________________

(Print Name)

(Social Security Number)

Home Address ________________________________________

______________________________________________

(Number and Street or Rural Route)

(Daytime Telephone Number)

_____________________________________________________
(City)

(State)

______________________________________________

(ZIP Code)

(E-mail Address)

Sign
Here: __________________________________________________________________________________________________
(Signature)
_____________________________________________________

______________________________________________

(Print Name)

(Social Security Number)

Home Address ________________________________________

______________________________________________

(Number and Street or Rural Route)

(Daytime Telephone Number)

_____________________________________________________
(City)

(State)

______________________________________________

(ZIP Code)

(E-mail Address)

Instructions to Certifying Officer: 1. Name(s) of the person(s) who appeared and date of appearance MUST be completed.
2. If a Medallion stamp is used, an original signature is required. 3. Person(s) must sign in your presence.
I CERTIFY that ______________________________________________________________________________ , whose identity(ies)
(Names of Persons Who Appeared)

is/are known or proven to me, personally appeared before me this _________________ day of _______________

__________

(Month)

(Year)

at _________________________________________________________ and signed this form.
(City, State)
________________________________________________________
(Signature and Title of Certifying Officer)
________________________________________________________
(Name of Financial Institution)
________________________________________________________
(Address)
________________________________________________________
(City, State, ZIP code)
________________________________________________________
(Telephone)

FS Form 5178

Department of the Treasury | Bureau of the Fiscal Service

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I CERTIFY that ______________________________________________________________________________ , whose identity(ies)
(Names of Persons Who Appeared)

is/are known or proven to me, personally appeared before me this _________________ day of _______________

__________

(Month)

(Year)

at _________________________________________________________ and signed this form.
(City, State)
________________________________________________________
(Signature and Title of Certifying Officer)
________________________________________________________
(Name of Financial Institution)
________________________________________________________
(Address)
________________________________________________________
(City, State, ZIP code)
________________________________________________________
(Telephone)

INSTRUCTIONS
IMPORTANT NOTICES
•
•
•
•
•

This form can't be used to transfer securities.
Only original signatures will be accepted (stamped signatures are not acceptable).
If any person signing this form is acting in a fiduciary capacity, failure to provide legal evidence may delay processing.
This form must be signed in all cases.
This form will not be accepted with alterations or corrections.

COMPLETION OF FORM
Item 1. LEGACY TREASURY DIRECT ACCOUNT INFORMATION
Provide your Legacy Treasury Direct Account Number. Your Legacy Treasury Direct Account Number is shown on your Statement of
Account, immediately above the Account Holdings section. Provide the name(s) under which the account is registered; this is shown in
the address block of your Statement of Account.
Item 2. TRANSACTION REQUESTED – Check the box next to all transactions you are requesting.
• CONSOLIDATION OF LEGACY TREASURY DIRECT ACCOUNTS – Mark this box to consolidate two or more of your Legacy
Treasury Direct accounts. All Legacy Treasury Direct accounts to be consolidated must be identical; the accounts must have the
same name, address, Taxpayer Identification Number, and payment information. Provide the number(s) of the account(s) from which
securities are to be moved on the lines beside "Legacy Treasury Direct Account Number(s) to be closed:", and provide the number of
the account into which the securities are to be deposited on the line beside "Surviving Legacy Treasury Direct Account No."
• NAME CHANGE – Mark this box to change the name that currently appears on your account. Provide the complete account name as
it should appear.
•
You may NOT use this form to remove the first-named owner from your account.
•
You may use this form to add or remove the name of a second-named owner or beneficiary; a certified signature is
required for this type of change.
•
You may use this form to change your registration to or from a trust IF the Taxpayer Identification Number is
NOT changing. If you are changing the registration to a trust, provide the name of the grantor, name(s) of the trustee(s),
and date on which the trust was created. If you want to change your registration to a trust and a different Taxpayer
Identification Number will be used, open an account in TreasuryDirect and transfer the securities to the TreasuryDirect
account with a Security Transfer Request (FS Form 5179). (For FS Form 5179, go to www.treasurydirect.gov.)
•
Minor name corrections, such as misspellings, adding or deleting a middle name or initial, or substituting a common
nickname require your signature, but the signature doesn’t have to be certified.
•
Name changes due to marriage must be signed "(current name) changed by marriage from (former name)" and, unless you
submit a copy of your marriage certificate, your signature must be certified. For name changes not due to marriage, you must
submit a certified copy of the legal document showing the name change. If supporting evidence is submitted, your signature to
the form does not have to be certified.
• ADDRESS CHANGE – Mark this box to change the address that currently appears on your account. Provide the complete address
as it should appear.
• TELEPHONE NUMBER CHANGE – Mark this box to change the telephone number or numbers that currently appear on your
account. Provide the correct number or numbers, including area codes and, if appropriate, your extension.
• PAYMENT INFORMATION CHANGE – Mark this box to change the direct deposit information that currently appears on your
account. Provide the complete direct deposit information as it should appear. If both the Legacy Treasury Direct account and the
receiving financial institution account are in the names of individuals, then at least one of the individuals named on the Legacy
Treasury Direct account must be named on the deposit account. A certified signature is required for any payment information
change.
FS Form 5178

Department of the Treasury | Bureau of the Fiscal Service

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•

TAXPAYER IDENTIFICATION NUMBER CORRECTION – Mark this box to correct the Taxpayer Identification Number that currently
appears on your account. Provide the correct number for the first-named owner.

Item 3. SIGNATURES AND CERTIFICATION
SIGNATURES – This form must be signed in all cases. The owner named on the Legacy Treasury Direct account, his or her authorized
representative, or the person entitled to the account must sign the form in ink, and provide his or her title (if applicable), mailing address,
daytime telephone number, and, if applicable, e-mail address. If there are two owners joined by the word "and," both must sign this
form if it involves a name change (other than a minor change), payment information change, or consolidation of accounts. If a
correction of the Taxpayer Identification Number is requested, the form must be signed by the first-named owner whose
Taxpayer Identification Number is shown.
Certification of the signature is required if you add or delete a beneficiary or second owner, if you change the payment information, if you
change your name (other than a minor change) and don't submit supporting evidence, if you change your registration from an individual
account to your grantor trust, or if you change your registration from a grantor trust to an individual account. You must wait until you are
in the presence of a certifying individual to sign this form.
If the account is registered in the name of an organization or corporation, a current Resolution for Transactions Involving Treasury
Securities (FS Form 1010) or your own corporate resolution must be submitted with this request. (For FS Form 1010, go to
www.treasurydirect.gov.)
Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association, created or organized in the United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• A domestic trust.
CERTIFICATION – If certification is applicable, each person whose certified signature is required must appear before and establish
identification to the satisfaction of an authorized certifying individual and sign and date the form in the individual’s presence. The
certifying individual must fully complete the certification blocks provided and affix the seal or stamp which is used when certifying requests
for payment. Acceptable certifications include a Financial Institution’s Official Seal or Stamp (such as Corporate Seal, Signature
Guaranteed Stamp, or Medallion Stamp). Brokers must use a Medallion Stamp (original signature is required). Authorized certifying
individuals include authorized employees of insured depository institutions and corporate central credit unions.
Please note that certification by a notary public is NOT acceptable.
WHERE TO SEND – Send the completed form to: Treasury Retail Securities Services, P.O. Box 9150, Minneapolis, MN 55480-9150.
Call us toll-free in the United States at 844-284-2676. Outside the U.S.? Call us at +1-304-480-6464. Legal evidence or documentation
you submit cannot be returned.
To ensure timely processing, this form must be received at least ten business days in advance of:
• the maturity date of the security, and
• an interest payment date for the security.
CONFIRMATION OF TRANSACTION(S) – You will receive a Legacy Treasury Direct Confirmation of Change in Investor Account
Information after your transaction has been processed. A Statement of Account will be sent for each account when Legacy Treasury
Direct accounts are consolidated.
NOTICE UNDER 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 address shown in "WHERE TO SEND" in the Instructions.

FS Form 5178

Department of the Treasury | Bureau of the Fiscal Service

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