Form PD-F-2243 Supplemental Statement for United States Securities

RESET
For BPD use only:
Customer Name

Customer No.

SUPPLEMENTAL STATEMENT FOR
UNITED STATES SECURITIES

PD F 2243
Department of the Treasury
Bureau of the Public Debt
(Revised May 2008)

OMB No. 1535-0013

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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 punishable by fine and/or imprisonment.
PRINT IN INK OR TYPE ALL INFORMATION

1.

The claim reporting the loss, theft, destruction, or nonreceipt of United States Securities applies to the
securities described in Item 5.

2.

The claim reporting the loss, theft, destruction, or nonreceipt of United States Securities applies to the
securities described in Item 5 rather than the securities described in the original application.

3.

I certify:
I had possession, custody, or control of the securities described in Item 5.
I have firsthand knowledge of the circumstances under which the securities described in Item 5 were
lost, stolen, or destroyed.
I had access to the None Selected

4.

described in Item 5.

I have been informed that

submitted
(Names of original applicants)

a claim reporting the

Select Choice from Drop Down List

of the United States Securities

(loss, theft, destruction, or nonreceipt)

described in Item 5. My knowledge of the securities is:

5. Description of Securities
TITLE OF SECURITY
(Identify securities by series, interest
rate, type, CUSIP, call and maturity
dates, as appropriate)

ISSUE
DATE

FACE AMOUNT
(Denomination)

SERIAL NUMBER

REGISTRATION
(Exactly as shown on the face of each security)

(If you need more space to describe your securities, use the continuation sheet on page 3.)

6. Signatures and Certification
I/We certify that I/we don't have possession or control of any of the securities described in Item 5 and that I/we don't have any further
information in regard to where they are or what became of them.
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 on account of 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.
You must wait until you are in the presence of a certifying officer to sign this form.

Sign Here ⇒
(Signature)

(Print Name)

(Number and Street or Rural Route)

(Social Security Number)

Home Address

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

E-Mail Address

Sign Here ⇒
(Signature)

(Print Name)

(Number and Street or Rural Route)

(Social Security Number)

Home Address

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

E-Mail Address
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

proven to me, personally appeared before me this

day of

,
(Month)

at

,
(Year)

, and signed this form.
(City)

(State)
(Signature and Title of Certifying Officer)

(OFFICIAL STAMP
OR SEAL)

(Number and Street or Rural Route)

(City)

(State)

I CERTIFY that

(ZIP Code)

, whose identity is known or

proven to me, personally appeared before me this

day of

,
(Month)

at

,
(Year)

, and signed this form.
(City)

(State)
(Signature and Title of Certifying Officer)

(OFFICIAL STAMP
OR SEAL)

(Number and Street or Rural Route)

(City)

(2)

(State)

(ZIP Code)

Continuation of description of securities in Item 5:
TITLE OF SECURITY
(Identify securities by series, interest
rate, type, CUSIP, call and maturity
dates, as appropriate)

ISSUE
DATE

FACE AMOUNT
(Denomination)

SERIAL NUMBER

REGISTRATION
(Exactly as shown on the face of each security)

(If you need more space to describe your securities, use a continuation sheet and attach it to the form.)
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INSTRUCTIONS
PURPOSE OF FORM – Use this form to support an application for relief on account of the loss, theft, destruction, or
nonreceipt of United States Securities.
COMPLETION OF FORM
ITEM 1.

Mark this box to show that the securities described in Item 5 are the missing securities referred to on the
original application. Describe the missing securities in Item 5.

ITEM 2.

Mark this box if incorrect serial numbers were provided on the original application. Describe the correct
missing securities in Item 5.

ITEM 3.

Mark the appropriate box(es) to indicate whether you had possession, custody, or control of the securities,
firsthand knowledge of the circumstances under which they were lost, stolen, or destroyed, or if you had
access to the securities.

ITEM 4.

Mark this box and complete this item when someone other than the original applicant(s) had custody or
knowledge of the loss. Furnish the name(s) of the original applicant(s) and provide all information
concerning your knowledge of the whereabouts of the securities. If you do not have any knowledge of their
whereabouts, state this. If the original applicant(s) or any other person claims to have mailed or delivered
the securities to you, state whether or not you received them. If you did not receive the securities, explain
why, if known (for example, wrong address used).

ITEM 5.

Furnish a complete description of the missing securities.

ITEM 6.

If Item 1 or 2 is checked, the form must be signed by the original applicant(s). If Item 3 or 4 is checked, the
form must be signed by the person having custody of the securities or knowledge of their loss. If any
person whose signature is required is a minor who does not have a court-appointed guardian, he/she can
sign the form on his/her own behalf if, in the opinion of the certifying officer, he/she is of sufficient
competency to understand the nature of the transaction. Otherwise, the form must be signed by both
parents on the minor's behalf. If the minor does not reside with either parent, the form must be completed
and signed by the person who furnishes the minor's chief support. The minor's age and social security
number must be furnished.
Each person whose signature is required must sign the form in ink, print his/her name, and provide his/her
home address and daytime telephone number. Each signature must be certified.

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. For a complete list of such
officers, see Department of the Treasury Circulars, Nos. 300 and 530, and Public Debt Series, Nos. 3-80 and 2-98.
WHERE TO SEND – Send the application and any additional information to the Department of the Treasury, Bureau of
the Public Debt, using the address listed below that is appropriate to the type of security involved:
•
HH/H Savings Bonds – PO Box 2186, Parkersburg, WV 26106-2186
•
E/EE/I Savings Bonds – PO Box 7012, Parkersburg, WV 26106-7012
•
Treasury Bills, Notes, Bonds, and TIPS – PO Box 426, Parkersburg, WV 26106-0426
NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
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 Public Debt 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 Public Debt 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 05 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 the correct address
shown in "WHERE TO SEND" above.

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