Form PD F 0974 E PD F 0974 E Affidavit Of Forgery For United States Savings Bonds

For official use only:
Customer Name		     			Customer No.	     
	PD F 0974 E Department of the Treasury Bureau of the Public Debt (Revised October 2010)			AFFIDAVIT OF FORGERY			OMB No. 1535-0067

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

1. Please complete the following.

Name

     

Social Security Number

     

Total amount of securities

     

Relationship

~     

Location where securities were cashed

     

Please answer the following questions as related to the attached to the best of your ability.

2. Were the photographs of the examined and were the signatures to the requests forged and made without proper authority? YES NO

If NO, explain:

     

     

3. Was any person authorized to , present them for , or receive any of their value? YES NO

If YES, explain:

     

     

4. Was reimbursement received because of the loss? YES NO

If YES, explain:

     

     

5. Do you know of any person who may have taken the securities, , cashed the securities, or received any of their value? YES NO

If YES, explain:

     

     

6.

(a)

Where were the securities kept at the time of loss or theft?

     

(b)

What was the location?

     

(Mailing Address)

(c)

Who placed the securities there?

     

When?

     

(d)

Who else had access to the securities?

     

7.

(a)

When were the securities lost or stolen?

     

(b)

What were the circumstances of the loss or theft?

     

     

8. Were any identification documents lost or stolen at the same time? YES NO

If YES, describe in detail:

     

9.

(a)

What action, including filing a police report, was taken to recover the securities?

     

     

(b)

What were the results of that action?

     

     

10. Description of securities

TITLE OF SECURITY	ISSUE DATE	FACE AMOUNT	IDENTIFYING NUMBER	REGISTRATION
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     

(If you need more space to describe your securities, use a continuation sheet.)

I certify, under penalty of perjury, and severally affirm and say that the information given is true to the best of my/our knowledge and belief.
Sign Here					     
	(Signature)				(Print Name)
Home Address	     				     
	(Number and Street, Rural Route and Box Number, or P.O. Box)				(E-mail Address)
	     				     
	(City)	(State)	(ZIP Code)		(Daytime Telephone Number)

I CERTIFY that		     						whose identity is known or was
			(Name of Person Who Appeared)
proven to me, personally appeared before me this						day of
							(Month / Year)
at					, and signed this form.
	(City, State)
(OFFICIAL STAMP OR SEAL)					(Signature and Title of Certifying Individual)
					(Name of Financial Institution)
					(Address)
ACCEPTABLE CERTIFICATIONS: Financial institution's official seal or stamp (such as corporate seal, signature guaranteed stamp,or medallion stamp). Brokers must use a medallion stamp.
					(City, State, ZIP Code)
(Notary certification is NOT acceptable.)
					(Telephone)

INSTRUCTIONS

USE OF FORM – This form may be used by any person named on the securities, or an authorized representative, to certify that the signatures to the requests for payment, form, or application related to United States Savings Securities were forged. Every question must be answered in detail and all possible information furnished.

ATTACHMENTS – If more space is needed for any item, use a plain sheet of paper and attach it to the form.

COMPLETION OF FORM

ITEM 1. Insert your name and Social Security Number. For "Relationship," show your ownership capacity in regard to the securities bearing your alleged signature; either choose an option in the drop-down menu or write your capacity. If you’re a representative, insert the name and Social Security Number for the person you represent and indicate the capacity in which you are acting. Insert the total amount (face or par) of forged securities, and the location where the securities were cashed.

ITEM 2. Mark the appropriate box to show if the signatures are forgeries and were made without your authorization. If the signatures were made by you or by someone else with your consent, check the “NO” box and explain fully.

ITEM 3. Mark the appropriate box to show if you authorized anyone to take any action concerning the securities. If “YES”, insert that person’s name and address and show the extent of authority.

ITEM 4. Mark the appropriate box to show if you have received reimbursement because of the loss. If “YES”, state what reimbursement you or anyone on your behalf received from any source. If anything of value has been received, give full details, including the name and address of the person or organization from which it was received. If you have been promised reimbursement, give the name and address of the person or organization who made the promise and explain clearly why this was done.

ITEM 5. Mark the appropriate box to show whether you have reason to believe any person had any connection with the loss, theft, or forgery of the securities. If “YES”, furnish the name and address of that person and give complete details, including the person's relationship to you.

ITEM 6. (a) and (b) Describe fully the place where the securities were kept and show whether they were under lock and key. (If the securities were mailed to you and never received, state “Not Received” and skip to Item 8.) (c) State who placed the securities there and the date. (d) Furnish the names and addresses of all persons who had access to the securities.

ITEM 7. State the date the loss or theft occurred, how it occurred, and who discovered the loss or theft.

ITEM 8. Mark the appropriate box to show if any identification documents were also lost or stolen. If “YES”, describe the documents and show whether they bore your signature and/or contained your physical description or photograph.

ITEM 9. Explain what was done to recover the securities, not only by you personally, but by any police, insurance, or similar agencies.

ITEM 10.Describe only the securities or checks to which the person shown in Item 1 is entitled, in whole or in part:

• 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.

SIGNATURE – You must sign the form in ink, print your name, and provide your home address, daytime telephone number, and, if applicable, e-mail address. Your signature must be certified (see "CERTIFICATION" below).

CERTIFICATION – You must appear before and establish identification to the satisfaction of an authorized certifying individual and sign the form in the individual’s presence. The certifying individual must affix the seal or stamp which is used when certifying requests for payment. Authorized certifying individuals are available at most banking institutions, including credit unions. For a complete list of such individuals, see Department of the Treasury Circulars, No. 530, and Public Debt Series, Nos. 3-80 and 2-98.

SUPPLEMENTAL EVIDENCE – If any person other than the person executing this affidavit had custody of the securities at the time of loss or theft, or has firsthand knowledge of the circumstances under which the securities were lost, stolen, or forged, that person must furnish an affidavit concerning his knowledge of the loss, theft, and/or forgery.

WHERE TO SEND – Send the completed form to the Department of the Treasury, Bureau of the Public Debt, PO Box 7014, Parkersburg, WV  26106‑7014.

NOTICE UNDER THE 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 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 15 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 this address; send to the address shown above in "WHERE TO SEND."