FS Form 3062-4 Claim for United States Savings Bonds Not Received

Claim for Relief on Account of the Non-receipt of United States Savings Bonds

sav3062-4

OMB: 1530-0048

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For official use only:

Customer No

Case or SR#

Customer Name

FS Form 3062-4 (Revised July 2020)

OMB No. 1530-0048

Claim for United States
Savings Bonds Not Received
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.

I/We, the undersigned, certify that the United States Savings Bonds described on this form have not been received, either by
me/us, or by anyone on my/our behalf. If the addressee has moved since the bonds were mailed, I/we also certify that an inquiry
was made at the former address.

1. DESCRIPTION OF BONDS
Describe the missing bonds in the spaces below. If you don’t know the bond serial numbers, provide all of the information
requested below and also indicate the total number of bonds that are missing.
ISSUE DATE
(Exact date or a
range of dates)

FACE
AMOUNT

INSCRIPTION
(Provide complete Social Security Number [for example, 123-45-6789], names, including
middle names or initials, and addresses [street, city, state] on the bonds.
If a bond was received as a gift, provide the purchaser's Social Security Number.)

BOND NUMBER

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

2. DETAILS OF THE PURCHASE
Purchaser’s name __________________________________________________________________________________
Purchaser’s Social Security Number ____________________________________
3. AUTHORITY – Provide details regarding your authority to complete a claim for the bonds.
Are you named on the bonds?

Yes

If Yes, skip to Item 4. If No, provide the following information:

Describe your authority: _______________________________________________________________________________
(Show authority: i.e., parent, guardian, conservator, legal representative, administrator, executor, etc.)

Are you court appointed?

Yes

(If Yes, see “LEGAL REPRESENTATIVE” in the instructions.)

4. MINORS – Provide details regarding any registrants who are currently minors. (See "MINORS" in the instructions.)
Is there a minor named on the bonds?

Yes

If No, skip to Item 5. If Yes, fully complete the following:

What is the minor’s:
Name? ______________________________________________________ DOB? _________________________
Social Security Number? _________________________________________
What is your relationship to the minor? __________________________________________________________________
Does the minor live with you?

FS Form 3062-4

Yes

Department of the Treasury | Bureau of the Fiscal Service

4. MINORS (continued)
If No, with whom? _____________________________________________________________________________
(Name)

(Relationship to Minor)

_____________________________________________________________________________
(Address)

Who provides the minor’s chief support?
_____________________________________________________________________________
(Name)

(Relationship to Minor)

_____________________________________________________________________________
(Address)

Are both parents able to sign the application for relief?

Yes

If Yes, skip to Item 5. If No, fully complete the following:
Why are you unable to obtain the signature? ________________________________________________________
Did that parent have access to the bonds?

Yes

Could that parent have possession of the bonds?

Yes

5. RELIEF REQUESTED – Indicate whether you want substitute bonds or payment. NOTE: Substitute bonds can’t be
issued in some cases, including if a bond is within one full calendar month of its final maturity.
A. Series EE or Series I Bonds: I/We hereby request

*Substitute Electronic Bonds

Payment by Direct Deposit

*When we reissue a Series EE or Series I savings bond, we no longer provide a paper bond.

The reissued bond is in
electronic form, in our online system TreasuryDirect. For information on opening an account in TreasuryDirect, go to
www.treasurydirect.gov.
B. Series HH Bonds: I/We hereby request

Substitute Paper Bonds

Payment by Direct Deposit

6. DELIVERY INSTRUCTIONS
A. For Electronic Substitute Bonds – Series EE or Series I
TreasuryDirect account number ________________________________
Account name ________________________________________________________________
Social Security Number or Employer Identification Number _______________________________
NOTE: You may add a secondary owner or beneficiary once bonds have been replaced in electronic form within your
TreasuryDirect account. For more information, access your account and click on “How do I” at the top of the page to find
instructions on how to add a secondary owner or beneficiary.
TAX LIABILITY: If the name of a living owner or principal coowner of the bonds is eliminated from the registration, the owner or principal
coowner must include the interest earned and previously unreported on the bonds to the date of the transaction on his or her Federal
income tax return for the year of the reissue. (Both registrants are considered to be coowners when bonds are registered in the form: "A"
or "B.") The principal coowner is the coowner who (1) purchased the bonds with his or her own funds, or (2) received them as a gift,
inheritance, or legacy, or as a result of judicial proceedings, and had them reissued in coownership form, provided he or she has received
no contribution in money or money's worth for designating the other coowner on the bonds. If the reissue is a reportable event, the
interest earned on the bonds to the date of the reissue will be reported to the Internal Revenue Service (IRS) by a Federal Reserve Bank
or Branch or the Bureau of the Fiscal Service under the Tax Equity and Fiscal Responsibility Act of 1982. THE OBLIGATION TO
REPORT THE INTEREST CANNOT BE TRANSFERRED TO SOMEONE ELSE THROUGH A REISSUE TRANSACTION. If you have
questions concerning the tax consequences, consult the IRS, or write to the Commissioner of Internal Revenue, Washington, DC 20224.
Unless we are otherwise informed, the first-named coowner will be considered the principal coowner for the purpose of this
transaction.

B. For Substitute Paper Bonds—Series HH
Mail Bonds To: _________________________________________________________________________
(Name)

_______________________________________________________________________________________
(Number and Street, Rural Route, or P O Box)

FS Form 3062-4

(City)

Department of the Treasury | Bureau of the Fiscal Service

(State)

(ZIIP Code)

C. For Direct Deposit Payment--Any Series of Bonds
Payee must provide a Social Security Number or Employer Identification Number:
______________________________________

__________________________________________

(Social Security Number of Payee)

(Employer Identification Number of Payee)

________________________________________________________________________________________
(Name/Names on the Account)

Bank Routing No. (nine digits and begins with 0, 1, 2, or 3): _______________________________
_________________________________________

Type of Account

Checking

Savings

(Depositor’s Account No.)

___________________________________________________

______________________________

(Financial Institution’s Name)

(Financial Institution’s Phone No.)

7. Signatures and Certification
I/We severally petition the Secretary of the Treasury for relief as authorized by law and, if relief is granted, acknowledge that the original
securities will become the property of the United States. Upon the granting of relief, I/we assign all our right, title, and interest in the
original securities to the United States and hereby bind myself/ourselves, my/our heirs, executors, administrators, successors and
assigns, jointly and severally: (1) to surrender the original securities to the Department of the Treasury should they come into my/our
possession; (2) to hold the United States harmless on account of any claim by any other parties having, or claiming to have, interests in
these securities; and (3) upon demand by the Department of the Treasury, to indemnify unconditionally the United States and repay to the
Department of the Treasury all sums of money which the Department may pay due to the redemption of these original securities, including
any interest, administrative costs and penalties, and any other liability or losses incurred as a result of such redemption. I/We consent to
the release of any information in this form or regarding the securities described to any party having an ownership or entitlement interest in
these securities.
I/We certify, under penalty of perjury, and severally affirm and say that the securities described on this form were never received, and that
the information given is true to the best of my/our knowledge and belief.
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)

(Email Address)

Sign
Here:___________________________________________________________________________________________________
(Signature)

_____________________________________________________

______________________________________________

(Print Name)

(Social Security Number)

Home Address ________________________________________

______________________________________________

(Number and Street or Rural Route)

_____________________________________________________
(City)

FS Form 3062-4

(State)

(Daytime Telephone Number)

______________________________________________

(ZIP Code)

Department of the Treasury | Bureau of the Fiscal Service

(Email Address)

Sign
Here:___________________________________________________________________________________________________
(Signature)

_____________________________________________________

______________________________________________

(Print Name)

(Social Security Number)

Home Address ________________________________________

______________________________________________

(Number and Street or Rural Route)

_____________________________________________________
(City)

(State)

(Daytime Telephone Number)

______________________________________________

(ZIP Code)

(Email Address)

Instructions to Certifying Officer: 1. Name(s) of the person(s) who appeared and date of appearance MUST be completed.
2. Original signature is required if a Medallion stamp is used. 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)

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)

FS Form 3062-4

Department of the Treasury | Bureau of the Fiscal Service

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)

INSTRUCTIONS
IF YOU LIVE IN A DECLARED DISASTER AREA: You need to complete only parts 1, 5, 6.B. and 7. Write the word “DISASTER”
on the top of the first page of the form and on the front of the envelope.
PURPOSE OF FORM – Use this form to apply for relief for not receiving United States Savings Bonds.
WHO MAY APPLY – This form must be completed and signed by all persons named on the bonds, or by an authorized representative.
ATTACHMENTS – If you need more space for any item, attach either a plain sheet of paper, or, for Part 1, a “Continuation Sheet for Listing
Securities” (FS Form 3500), available at http://www.treasurydirect.gov/forms/sav3500.pdf.
PROOF OF DEATH – If a registrant is deceased, you must submit a certified copy of his or her official death certificate with this form.
LEGAL REPRESENTATIVE – If you were appointed as legal representative because:
•
the owner is deceased (with no surviving coowner or beneficiary named on the bonds), or
•
the owner or coowner is a minor, or
•
the owner or coowner is incapacitated,
complete the form and submit a court certificate or certified copy of your letters of appointment, under court seal and dated within one year
of submission, showing the appointment is still in full force. If your name and official capacity are shown in the registration of the bonds,
evidence of your appointment is not necessary.
If no legal representative has been appointed for a deceased or incompetent owner, advise the Bureau of the Fiscal Service and additional
instructions will be provided.
1. DESCRIPTION OF BONDS
Describe the missing bonds by bond serial number. If you don't know the bond serial numbers, you must provide the exact issue date or
a range of dates, and the Social Security Number, name (including middle name or initial), and complete address (street, city, state) that
appear on the bonds. Also state the total number of missing bonds. If you need more space, attach either a “Continuation Sheet for
Listing Securities” (FS Form 3500), available at http://www.treasurydirect.gov/forms/sav3500.pdf, or a plain sheet of paper.
2. DETAILS OF THE PURCHASE

Provide the requested information regarding the purchase of the bonds.
3. AUTHORITY
Provide details regarding your authority to complete a claim for the missing bonds. If you have been court-appointed, see "LEGAL
REPRESENTATIVE" above.
4. MINORS
A minor (who does not have a court-appointed guardian) who is requesting payment or who is named on Series HH bonds may complete
and sign the form on his or her own behalf if, in the opinion of the certifying officer, he or she is of sufficient competency and
understanding to comprehend the nature of the transaction. The parents or parent with whom the minor resides must complete this item if
a minor is named on the bonds and he or she is not of sufficient competency and understanding to complete the form on his or her own
behalf, or is requesting electronic substitute bonds for Series EE or Series I. Provide the minor’s name, date of birth, Social Security
Number, and all other requested information. If the minor does not reside with either parent, the form must be completed and signed by
the individual who furnishes the minor’s chief support.

FS Form 3062-4

Department of the Treasury | Bureau of the Fiscal Service

5. RELIEF REQUESTED
Indicate whether you want substitute bonds or payment by direct deposit.
•
•
•
•

For Series EE and Series I bonds, we no longer issue substitute bonds in paper form. We issue those substitute bonds in
electronic form, in our online system TreasuryDirect.
If you want substitute Series EE bonds or substitute Series I bonds, provide the TreasuryDirect account number. If you don’t
have an account, you may open one at www.treasurydirect.gov.
Series EE and Series I bonds issued February 2003 and later are not eligible for payment until one full year after issue; if
payment is requested and such bonds are less than one year old, substitute bonds will be issued instead.
If substitute bonds are requested and a bond is within less than one full calendar month of reaching its final maturity, or has
reached final maturity, payment will be made instead.

6. DELIVERY INSTRUCTIONS
Complete either section A or B. Which section is appropriate for you depends on which series of bonds you have and whether you want
payment or substitute bonds.
7. SIGNATURES AND CERTIFICATION
Each person whose signature is required must appear before and establish identification to the satisfaction of an authorized certifying
officer. The signatures to the form must be signed in the officer's presence. The certifying officer must affix the seal or stamp which is
used when certifying requests for payment. Authorized certifying officers are available at financial institutions, including credit unions, in
the United States. Certification by a notary isn’t acceptable. Examples of acceptable seals and stamps:
•
The financial institution’s official seal or stamp, including: Signature Guaranteed seal or stamp; Endorsement Guaranteed seal
or stamp; Corporate seal or stamp (a corporate resolution isn’t required); or Issuing or paying agent seal or stamp (including
name, location, and four-digit identification number or nine-digit routing number)
•
The seal or stamp of Treasury-recognized Signature Guarantee Programs or other Treasury-approved Medallion Programs.
WHERE TO SEND
Send this form and any additional information to Treasury Retail Securities Services, PO Box 214, Minneapolis, MN 55480-0214. Legal
evidence or documentation you submit cannot be returned.
For Bond-Related Inquiries:
•
Email: [email protected]

•

Phone: 844-284-2676 (toll free)

•

Fax: 612-629-4285

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 appropriate address shown in "WHERE TO SEND" in the Instructions.

FS Form 3062-4

Department of the Treasury | Bureau of the Fiscal Service

File Type	application/pdf
Author	Brenda A. Stauffer
File Modified	2022-07-28
File Created	2020-07-01