Form FS Form 1849 FS Form 1849 Disclaimer and Consent With Respect to United States Tre

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For official use only:

Customer No

Case or SR#

Customer Name

FS Form 1849 (Revised August 2019)

OMB No. 1530-0059

Disclaimer and Consent with Respect to
United States Treasury Securities
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.

1. DESCRIPTION OF SECURITIES
TITLE OF SECURITY

ISSUE
DATE

FACE/PAR
AMOUNT

BOND OR ACCOUNT
NUMBER

REGISTRATION

(If you need more space, use the table on page 2.)

2. DISCLAIMER AND CONSENT - I disclaim all my right, title, and interest in and to the securities described on this form and consent to
the payment, refund of purchase price, transfer, reissue, or other disposition of them by:
_____________________________________________________________________________________________________________
(Name)
_____________________________________________________________________________________________________________
(Address)
My disclaimer and consent are given for the following reason(s):__________________________________________________________
_____________________________________________________________________________________________________________
3. SIGNATURE AND CERTIFICATION - Sign in ink in the presence of a certifying officer and provide the requested information.
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 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 1849

Department of the Treasury | Bureau of the Fiscal Service

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Continuation of description of securities in item 1:
TITLE OF SECURITY

ISSUE
DATE

FACE/PAR
AMOUNT

BOND OR ACCOUNT
NUMBER

REGISTRATION

(If you need more space, attach either FS Form 3500 (see www.treasurydirect.gov/forms/sav3500.pdf) or a plain sheet of paper.

INSTRUCTIONS
USE OF FORM - Use this form to disclaim your right, title, and interest to United States Treasury Securities and consent to the payment,
refund of purchase price, transfer, reissue, or other disposition of them by another person. A minor or person under legal disability may
not complete this form.
1. DESCRIPTION OF SECURITIES
•
TITLE OF SECURITY – Identify each security by series, interest rate, type, CUSIP, call and maturity date, as appropriate.
If describing a check, insert the word “check.”
•
ISSUE DATE – Provide the issue date of each security or check.
•
FACE AMOUNT – Provide the face amount (par or denomination) of each security or check.
•
IDENTIFYING NUMBER (if applicable) – Provide the serial number of each security, the confirmation number, or the check
number.
• REGISTRATION – Provide the registration of each security, check, or account; also provide the account number, if any.
2. DISCLAIMER AND CONSENT
Show the name and address of the person to whom you are conveying your interest in the securities. Give the reason(s) you are disclaiming
your right, title, and interest in the securities and consenting to the payment, refund of purchase price, transfer, reissue, or other disposition of
them by another person.
3. SIGNATURE AND 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 fully complete the certification form provided and affix the seal or stamp which is used when
certifying requests for payment. Authorized certifying officers are available at most financial institutions, including credit unions.
Where to Send – Unless otherwise instructed in accompanying correspondence send this form, the securities, if any, and any additional
information to the appropriate address. Legal evidence or documentation you submit cannot be returned.
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•
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HH and H savings bonds – Treasury Retail Securities Services, PO Box 2186, Minneapolis, MN 55480-2186
Other paper savings bonds – Treasury Retail Securities Services, PO Box 214, Minneapolis, MN 55480-0214
Securities in TreasuryDirect – Treasury Retail Securities Services, PO Box 7015, Minneapolis, MN 55480-7015
Securities in Legacy Treasury Direct – Treasury Retail Securities Services, PO Box 9150, Minneapolis, MN 55480-9150
Paper marketable securities – Treasury Retail Securities Services, PO Box 9150, Minneapolis, MN 55480-9150

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 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 this
address; send to the address shown in "WHERE TO SEND" above.

FS Form 1849

Department of the Treasury | Bureau of the Fiscal Service

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