FS Form 5235 Report of Non-Receipt, Loss, Theft, or Destruction of a

RESET

For official use only:

Customer No

Case or SR#

Customer Name

FS Form 5235 (Revised August 2022)

OMB No. 1530-0042

Report of Nonreceipt, Loss, Theft, or Destruction
of a Check and Application for Replacement
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. RETURN THIS FORM TO:
Treasury Retail Securities Services, PO Box 9150, Minneapolis, MN 55480-9150

2. REQUESTED ACTION:
I/We hereby report the nonreceipt, loss, theft, or destruction of a check issued in connection with United States securities and request
issuance of a replacement payment. I/We
have requested
hereby request
. . . that a stop-payment order be placed against the check described in Item 4.

3. SECURITY DESCRIPTION. The check was issued in connection with
a. Paper U.S. Savings Bonds or Retirement Bonds:
Series E

Series EE

Savings Notes

Series I

Retirement Plan Bonds

Series H

Series HH

Individual Retirement Bonds

b. U.S. Treasury Marketable Securities:
Legacy Treasury Direct® account number _____________________________ (replacement payment may be made by Direct Deposit)
Bill

Note

Bond

TIPS ______________

Coupon Bond

Registered Note

(Term)

Paper Securities
Coupon Note

Registered Bond

Other ___________________________

c. Electronic U.S. Treasury Securities held in TreasuryDirect
Series E

Series EE

Series I

C of I (Certificate of Indebtedness)

Bill

Note

Bond

TIPS ______________
(Term)

d. Additional identifying information (loan title, pieces, face amount, form(s) of registration):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

4. CHECK DESCRIPTION. The check was issued in connection with:
a. Type of payment:
Principal

Interest

Discount or Refund

Coupons

Other _________________

b. Date of payment: ________________
FS Form 5235

Department of the Treasury | Bureau of the Fiscal Service

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c. Social Security Number of first-named payee: _________________________________
d. Amount of check: ________________________

e. Serial number of check (if known) ________________________

f. Name(s) inscribed on the check
_____________________________________________________________________________________________________________
g. The check was
Never received

Received then lost

Received then stolen

h. If lost, stolen, or destroyed, was the check endorsed?

Yes

Received then destroyed
No

If Yes, show the exact form of endorsement:

_____________________________________________________________________________________________________________
i. Describe the circumstances surrounding the loss, theft, or destruction:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
j.
I hereby warrant that all other payees named on the check(s) did not have access to the check. Therefore, I request waiver of
the requirement for all other payees to execute the application and agreement.

5.

INDEMNIFICATION AGREEMENT AND SIGNATURE(S):

In consideration of the issuance of a replacement payment, I/we agree that if the missing check ever comes into my/our possession or
under my/our control, I/we will return it to the Bureau of the Fiscal Service or a Federal Reserve Bank. Further, I/we indemnify and hold
harmless the United States of America, the Department of the Treasury, and the payor Federal Reserve Bank, against all claims or
demands and all loss, damage, and expense, including legal fees and expenses, that may be incurred from paying the check reported lost
or refusing to pay the check if presented.
Sign in ink in the presence of a certifying officer and provide the requested information.
Sign
Here: __________________________________________________________________________________________________
(Payee's Signature)

_____________________________________________________

______________________________________________

Mailing Address ______________________________________

______________________________________________

_____________________________________________________

______________________________________________

(Print Name)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

(Social Security Number)

(Daytime Telephone Number)

(E-mail Address)

Sign
Here: __________________________________________________________________________________________________
(Second Payee's Signature)

_____________________________________________________

______________________________________________

Mailing Address ______________________________________

______________________________________________

_____________________________________________________

______________________________________________

(Print Name)

(Number and Street or Rural Route)

(City)

FS Form 5235

(State)

(ZIP Code)

(Social Security Number)

(Daytime Telephone Number)

Department of the Treasury | Bureau of the Fiscal Service

(E-mail Address)

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Instructions to Certifying Officer:
1. Name of the person(s) who appeared and date of appearance MUST be completed.
2. Original signature required if 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 _______________
at ___________________________________________________ and signed this form.

(Month)

__________
(Year)

(City, State)

________________________________________________________
(Signature and Title of Certifying Officer)
________________________________________________________
(Name of Financial Institution)
________________________________________________________
(Address)
________________________________________________________
(City, State, ZIP code)
________________________________________________________
(Telephone)

SEE INSTRUCTIONS FOR ACCEPTABLE CERTIFICATION

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 _______________
at ___________________________________________________ and signed this form.

(Month)

__________
(Year)

(City, State)

________________________________________________________
(Signature and Title of Certifying Officer)
________________________________________________________
(Name of Financial Institution)
________________________________________________________
(Address)
________________________________________________________
(City, State, ZIP code)
________________________________________________________
(Telephone)

SEE INSTRUCTIONS FOR ACCEPTABLE CERTIFICATION

INSTRUCTIONS
USE OF FORM – Payee(s) can use this form to report the nonreceipt, loss, theft, or destruction of fiscal agency checks and
Treasury checks, and to apply for a replacement payment. The form provides the necessary information to place a hold on
the payment of the missing check and constitutes an application for the issuance of a replacement payment. Before a
replacement payment can be issued, additional evidence and a bond of indemnity may be required.
COMPLETION OF FORM – Print clearly in ink or type all information requested. If more space is needed for any item, use a
plain sheet of paper and attach it to this form.

FS Form 5235

Department of the Treasury | Bureau of the Fiscal Service

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ITEM 1.

This item is completed by the servicing office, advising you where to return the completed form.

ITEM 2.

Mark the appropriate box regarding stop-payment.

ITEM 3.

Mark the appropriate box(es) to show for what type(s) of security(ies) the check was issued. Provide any
additional identifying information in Item 3d.

ITEM 4.

Furnish all requested information:
a. Show the type of payment for which the check was issued.
b. Furnish the date of payment.
c. Furnish the first-named payee's Social Security Number.
d. Show the amount of the check.
e. Provide the serial number of the check, if known.
f. Provide the names that were inscribed on the check.
g. Indicate whether the check was never received, or received and then lost, stolen, or destroyed.
h. Indicate whether the check was endorsed and, if so, provide the exact form of endorsement.
i. If the check was lost, stolen, or destroyed after receipt, furnish the circumstances of the loss, theft, or
destruction.
j. Mark this box if the other payees named on the check did not have access to the check and you are
requesting a waiver of the requirement for all payees to join in executing the application and
agreement.

ITEM 5.

Sign the form in ink and provide your complete home address, daytime telephone number, and e-mail address,
if applicable. If there are two payees, both must sign unless Item 4k is marked. Each signature must be certified
(see "CERTIFICATION" section below).

CERTIFICATION – You must appear before and establish identification to the satisfaction of an authorized certifying officer.
The form must be signed in the officer’s presence. The certifying officer must affix the seal or stamp that is used when
certifying requests for payment. Authorized certifying officers are available at most financial institutions, including credit
unions. 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 the completed form to the address shown in Item 1.
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 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 in Item 1 on Page 1.

FS Form 5235

Department of the Treasury | Bureau of the Fiscal Service

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