Form PD-F-4239 Request by owner to payment or reissue of U.S. Savings B

RESET
For BPD use only:
Customer Name

Customer No.

PD F 4239 E
Department of the Treasury
Bureau of the Public Debt
(Revised April 2005)

OMB No. 1535-0063

REQUEST BY OWNER OR PERSON ENTITLED TO PAYMENT
OR REISSUE OF UNITED STATES SAVINGS BONDS/NOTES DEPOSITED IN
SAFEKEEPING WHEN ORIGINAL CUSTODY RECEIPTS ARE NOT AVAILABLE

IMPORTANT: Follow instructions in filling out this form. You should be aware that the making of any false, fictitious, or fraudulent claim or statement
to the United States is a crime that is punishable by fine and/or imprisonment.

PRINT IN INK OR TYPE ALL INFORMATION

To: BUREAU OF THE PUBLIC DEBT, PO Box 7012, Parkersburg, WV 26106-7012.

1. I

,

,

(Name)

(Social Security Number)

certify that United States Savings Bonds, Nos.

were held in safekeeping at:

Office of the Treasurer of the United States,
Federal Reserve Bank of

,

that I am the person lawfully entitled to claim the bonds as:
owner
coowner
beneficiary
legal representative of
person entitled to the estate of
other (explain)
and that the original Custody Receipts were mislaid, lost, or stolen and, after a diligent search, have not been found.
I agree to return the original receipts to Public Debt for cancellation if they are ever located.
2. I request:

payment of the current redemption value by check.
payment of the current redemption value by Direct Deposit.
new bonds in the same form of registration as the originals.
new bonds in the following form of registration:

New Registration:

Social Security Number of owner or first-named coowner:

(First name)

(Middle name or initial)

(Number and Street or Rural Route)

(Last name)

(City)

(State)

(ZIP Code)

If a coowner or beneficiary is desired, complete the following line:
(First name)

(Middle name or initial)

as

(Last name)

coowner
beneficiary

3. Mail the bonds or check to:
(Name)

(Number and Street or Rural Route)

(City)

(State)

(ZIP Code)

4. Signatures - You must wait until you are in the presence of a certifying officer to sign this form.
(Signature)
(Signature)

(Daytime Telephone No.)

(Signature)
(Signature)

(Daytime Telephone No.)

5. Certification - Certifying Officer – The individuals must sign in your presence.

Complete the certification and affix your stamp or seal.

I CERTIFY that
whose identity is known or was proven to me, personally

,

I CERTIFY that
whose identity is known or was proven to me, personally

,

appeared before me this

,

appeared before me this

,

day of

day of

(Month)

,

at
(Year)

(Month)

(City)

(Year)

and signed this form.
(OFFICIAL STAMP
OR SEAL)

,

at

State)

(City)

State)

and signed this form.
(Signature of certifying officer)

(OFFICIAL STAMP
OR SEAL)

(Signature of certifying officer)

(Title of certifying officer)

(Title of certifying officer)

(Address)

(Address)

INSTRUCTIONS
USE OF FORM – Use this form to request payment or reissue of United States Savings Bonds/Notes deposited for safekeeping with the Office of
the Treasurer of the United States or a Federal Reserve Bank ONLY when the original safekeeping custody receipts are not available.
(If safekeeping receipts are available, they must be submitted to the address shown on this form.)
WHO MAY COMPLETE THE FORM – The form must be completed by the owner, coowner, surviving beneficiary, legal representative of the
estate of a deceased or incompetent owner, or the person entitled to the estate of a deceased owner. If the original bonds are registered in
coownership form, this form must be signed by the coowner who deposited the bonds for safekeeping. Otherwise, the coowner's agreement or
evidence of his/her death is required.
EVIDENCE – The following evidence is required to support the request:
Request by:
Evidence Required
1. Surviving coowner or
A copy of the deceased registrant's death certificate, certified or sworn to by the State or local registrar,
beneficiary
under seal, to be a true and correct copy taken from the official records.
2. Legal representative of the
estate of a deceased or
incompetent owner

A court certificate or a certified copy of the representative's letters of appointment, under seal of the
court, showing that the appointment is still in full force and effect. If there is no legal representative in
the case of a deceased or incompetent owner or the decedent's estate has been fully administered and
closed, Public Debt must be so informed and further instructions will be provided.

COMPLETION OF FORM
• ITEM 1. Check the appropriate boxes to indicate where the bonds were held and your entitlement to them. List the bonds by serial number.
• ITEM 2. Mark the appropriate box to indicate whether payment or reissue is desired. For payment by Direct Deposit, also see Item 3 below.
If new bonds are desired and the bonds are to be reissued in a different form of registration than the originals, show the new
registration. If the applicant is the survivor of two persons named on the bonds, a new coowner or beneficiary may be designated
but proof of death of the other person must be furnished (see EVIDENCE above). If a security has matured or will reach maturity
before the reissue can be processed, payment will be issued. All Savings Bonds of Series A, B, C, D, F, G, J, and K, and Savings
Notes have reached final maturity and must be redeemed.

• ITEM 3. Furnish the name and address where the bonds or check are to be mailed. If payment by Direct Deposit is preferred, do not provide
delivery instructions in Item 3. Instead, complete a Direct Deposit form, PD F 5396 or SF 1199A, and submit it with this application.
Forms SF 1199A are available at financial institutions in the United States. PD F 5396 is available for download on the Internet at
www.treasurydirect.gov. The financial institution designated to receive the payment can assist in the completion of the Direct
Deposit form.
• ITEM 4. Sign the form and provide your daytime telephone number. The signature of a registered owner should be in the same form as that
appearing on the bonds. The signature of a representative or fiduciary must be in the same form as that shown in the court papers
or other evidence of authority and must be followed by the proper title and reference to the estate, as for example, "John W. Smith,
administrator of the estate of Henry L. Smith, deceased."
• ITEM 5. Each person whose signature is required 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 complete the certification forms provided and
impress the seal or stamp used when certifying requests for payment. Authorized officers are available at banking institutions,
including credit unions, in the United States. For a complete list of such officers, see Department of the Treasury Circulars No. 530,
current revision, and Public Debt Series No. 3-80.
WHERE TO SEND – Send the completed form and evidence, if any, to the Department of the Treasury, Bureau of the Public Debt, PO Box 7012,
Parkersburg, WV 26106-7012.
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
We're asking for the information on this form to assist us in processing your securities transaction requests. Our authority comes from 31 U.S.C. Ch. 31 which
authorizes the Treasury Department to borrow money to pay the public debt of the United States. Also, 26 U.S.C. 6109 requires us to use your SSN on certain
forms when we report taxable income to IRS. It's voluntary that you provide the requested information, but without it, we may not be able to process your transaction
requests. Information concerning your securities holdings and transactions is considered confidential under Treasury regulations (31 CFR Part 323) and the Privacy
Act. However, the following routine uses of this information may include disclosure to the following persons or entities: agents and contractors who help us manage
the public debt; others entitled to the securities or payment; agencies (including disclosure through approved computer matches) determining eligibility for benefits,
finding persons we've lost contact with, or helping us collect debts; agencies for investigations or prosecutions; courts, counsel, and others for litigation and other
proceedings; a Congressional office asking on your behalf; and as otherwise authorized by law.
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 Public Debt, Forms Management Officer,
Parkersburg, WV 26106-1328. DO NOT SEND completed form to the above address; send to correct address shown in "WHERE TO SEND" above.

(2)

PD F 4239