MF 6006 Mutilated Coin Redemption Program Instructions and Appli

Privacy Act Notice
31 U.S.C. § 5120, 31 U.S.C. § 5131, 31 U.S.C. § 5136, and 31 C.F.R. part 100
authorize the collection of this information. The purpose of this collection is to provide
the United States Mint with information needed to determine your eligibility to participate
in the United States Mint’s Mutilated Coin Redemption Program. Submitting this
information is voluntary, but failure to provide the requested information may delay or
prevent the United States Mint from processing, evaluating, and/or granting your
mutilated coin redemption request. For more information on this collection, including
with whom your information may be shared, please visit:
https://www.usmint.gov/news/consumer-alerts/mutilated-coin-program/instructions.

Paperwork Reduction Act Notice
The information collected will be used for the U.S. Government to process your
Mutilated Coin Redemption Application. The estimated burden associated with this
collection of information is 60 minutes per response. The collection of information is
required for reimbursement. Comments concerning the accuracy of this burden
estimate and suggestions for reducing this burden is to be directed to the Department
of Treasury, Customer Service, Manufacturing, United State Mint, 801 9th St. N.W.,
Washington, D.C. 20220. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a valid control
number assigned by OMB.

Mutilated Coin Redemption Program Instructions
Follow the steps below to submit the mutilated coin submission application. Each
company or individual (collectively “participants”) who physically transports, mails, or
ships or causes mutilated United States coins to the United States Mint (U.S. Mint)
for redemption is required to submit an application. For general redemption
information and acceptance criteria, visit the Mutilated Coin Redemption Program
(the “Program”) page at
https://www.usmint.gov/news/consumer-alerts/mutilated-coin-program and please
review the applicable regulations appearing at 31 Code of Federal Regulations, Part
100, Subpart C, Request for Examination of Coin for Possible Redemption.
1. Complete the following information below on the fillable form.
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Section 1.1: Parent Company Information
Section 1: Company Information
Section 2: Individual Information
Section 3: Electronic Funds Transfer Information
Section 4: Chain of Custody Information
Section 5: Acknowledgement and Signature
Section 6. Mutilated Coin Redemption Program – Third Party/Broker
SF 3881: ACH Vendor/Miscellaneous Payment Enrollment Form

2. Be sure to provide all applicable information.
(Note: Those submitting as an individual do not need to provide a Tax Identification
Number).
3. Print the completed information and compile it for submission.
4. Submit the application with original signature via United States Postal Service
mail to:
United States Mint
Attn: Mutilated Coin Redemption Program
801 9th Street, N.W.
Washington, DC 20220
Note: Do NOT email this information due to the sensitivity of the information requested.
5. Those submitting small lots of 35 pounds maximum per shipment (70 pounds
yearly max), send the mutilated coins to:
United States Mint
Attn: The Mutilated Coin Room
151 North Independence Mall East
Philadelphia, PA 19106-1886
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6. Those submitting large lots, not to exceed 1,000 pounds per month, submit
an application and await instructions from the U. S. Mint before submitting mutilated coins.
Follow the Quality and Packaging Standards for Bulk Deliveries at
https://www.usmint.gov/news/consumer-alerts/mutilated-coin-program/bulk-deliveries
in addition to any other instructions from the U.S. Mint
7. Contact the U.S. Mint with questions at [email protected] or
202-354-7760.

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Mutilated Coin Redemption Program Application Form
Please fill out the applicable company or individual information below.

Section 1: Company Information (if applicable)
The personal information requested should represent the individual or the point of
contact (POC) representing the company submitting the mutilated coins for
reimbursement.
Include all of the information listed below in your application:
Company Name:
DBA (if applicable):
Form of Ownership:
In which year was the company established:
Tax ID Number or Employer ID Number:
Street Address (street number and name):
City or Town:

State:

Zip Code:

Country:
Company Website:
Company Phone Number:
State where registered (if applicable):
Registration Number (if applicable):
Designate a POC who will serve as the sole POC for application status and
information:

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Section 1.1: Parent Company Information (if applicable)
If the company is a subsidiary of a parent company, the information listed below is also
required with the application.
Parent Company Name:
Form of Ownership:
Tax ID Number or Employer ID Number:
Street Address (street number and name):
City or Town:
State:
Zip Code:
Country:
Company Phone Number:
Company Website:
State where registered:
Registration Number:
In which year was the parent company established?:
List any other names or addresses the parent company has had in the last 10 years:
1. Other Name:
Address:
2. Other Name:
Address:
3. Other Name:
Address:

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Section 2: Individual Information (if applicable)
The personal information requested should represent the individual submitting the
mutilated coins for reimbursement.
Include all of the information listed below in your application:
Last Name:
First Name:

Middle Initial:

Other names used (if any):
Street Address (street number and name):
Apartment number:
City or Town:

State:

Country:
Email Address:
Telephone Number:

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Zip Code:

Section 3: Electronic Funds Transfer (EFT) Information
All reimbursements are processed through the Automated Clearing House (ACH). A
valid United States bank account is required to receive payment for mutilated coin
reimbursement.
Complete the ACH Vendor/Miscellaneous Payment Enrollment Form (SF3881)
included with the application.
(Note: Do not include your Social Security Number on the form)

Section 4: Chain of Custody Information
All participants must include all of the information listed below in your application in as much
detail as possible.
List the weight (in U.S. pounds) of each denomination category submitted:
Golden Dollars:

lbs.

Susan B. Anthony Dollars (SBA):

lbs.

Dimes, Quarters, Half Dollars:

lbs.

Nickels:

lbs.

Pennies:

lbs.

Pennies pre 1983:

lbs.

List your anticipated monthly and annual submission amount in pounds:
lbs. monthly
lbs. annually

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Provide a detailed description of how you or the company came into possession of these
mutilated coins. (Note: For applicants who obtained mutilated coins from a third
party/broker, please also complete Section 5: Mutilated Coin Redemption Program –
Third Party/Broker)

Were any of the coins were imported from outside of the United States?
Yes

No

Provide a detailed description of how the coin(s) became mutilated.

Describe any steps you took to inspect these mutilated coins.

Describe any steps you took to clean these mutilated coins.

Provide any additional or supplementary information (not required)

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Section 5: Mutilated Coin Redemption Program –
Third Party/Broker(s)
For applicants who obtained mutilated coins from a third party/broker, follow the
instructions below; if you do not, proceed to Section 6.
Please provide the total number of companies or individuals that have
provided mutilated coins to you (as part of coins you plan to submit to the
U.S. Mint).
For each individual or company, please provide information below. Add
additional pages if necessary.
1. Name of company or individual:
DBA (if applicable):
Address of company or individual:
Point of contact name and phone number:
Total amount of mutilated coins submitted to you (denomination and weight):
Golden Dollars:

lbs.

Susan B. Anthony Dollars (SBA):

lbs.

Dimes, Quarters, Half Dollars:

lbs.

Nickels:

lbs.

Pennies:

lbs.

Pennies pre 1983:

lbs.

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How often do you receive mutilated coins from the company or individual?

If you use an agent/representative between you and the companies or
individuals listed above, please provide the name, address and phone number
for each agent:

Provide a detailed description of how third party came into possession of these
mutilated coins:

What steps have you (or your organization) taken to ensure the mutilated
coins you have obtained are genuine U.S. coins?

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2. Name of company or individual (if applicable):
DBA (if applicable):
Address of company or individual:
Point of contact name and phone number:
Total amount of mutilated coins submitted to you (denomination and weight):
Golden Dollars:

lbs.

Susan B. Anthony Dollars (SBA):

lbs.

Dimes, Quarters, Half Dollars:

lbs.

Nickels:

lbs.

Pennies:

lbs.

Pennies pre 1983:

lbs.

How often do you receive mutilated coins from the company or individual?

If you use an agent/representative between you and the companies or
individuals listed above, please provide the name, address and phone number
for each agent:

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Provide a detailed description of how third party came into possession of these
mutilated coins:

What steps have you (or your organization) taken to ensure the mutilated
coins you have obtained are genuine U.S. coins?

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3. Name of company or individual:
DBA (if applicable):
Address of company or individual:
Point of contact name and phone number:

Total amount of mutilated coins submitted to you (denomination and weight):
Golden Dollars:

lbs.

Susan B. Anthony Dollars (SBA):

lbs.

Dimes, Quarters, Half Dollars:

lbs.

Nickels:

lbs.

Pennies:

lbs.

Pennies pre 1983:

lbs.

How often do you receive mutilated coins from the company or individual?

If you use an agent/representative between you and the companies or
individuals listed above, please provide the name, address and phone number
for each agent:

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Provide a detailed description of how third party came into possession of these
mutilated coins:

What steps have you (or your organization) taken to ensure the mutilated
coins you have obtained are genuine U.S. coins?

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Section 6: Acknowledgement and Signature
Please indicate your acknowledgement to the statements below and sign and submit
your original signature with your application.
1. Acknowledge (yes or no) the following statement: I understand that should the
weights differ between what is claimed here and the weight measurement reading by
the U.S. Mint, that the weight measured by the U.S. Mint will be the weight used to
calculate the redemption value paid.
Yes

No

2. Acknowledge (yes or no) the following statement: Any changes to applications
received (e.g., quantity, source) must be submitted and approved in writing.
Yes

No

3. Acknowledge (yes or no) the following statement: The applicant is responsible for all
shipping costs associated with the submission and retrieval of coins to the Program.
Yes

No

I have read and understood the instructions for submitting material to the United States
Mint Mutilated Coins Redemption Program. My submission is compliant with the
Program’s acceptance criteria stated on the United States Mint’s website and 31
C.F.R. Part 100, subpart C. I understand that if this submission is not found to be
compliant with those requirements, I will be responsible for arranging return shipping or
that the property will be considered abandoned if not retrieved within 30 days of
notification. I understand that counterfeit coins are subject to forfeiture under 18 U.S.C.
492 and that if my submission contains counterfeits, the entire submission will be turned
over to law enforcement authorities for forfeiture. All information I have provided to the
U.S. Mint is accurate to the best of my knowledge. I affirm the information provided is
true, complete, and correct under penalty of perjury.
Printed Name:
Title (if company):
Company name (if company):
Signature:
Date of Signature (mm/dd/yyyy):

DEPARTMENT OF THE TREASURY
United States Mint

MF 6006
(09/2020)

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