Form FS Form 1022 FS Form 1022 Report/Application for Relief on Account of Loss, Theft

RESET
For official use only:
Customer Name

Customer No.

FS Form 1022
Department of the Treasury
Bureau of the Fiscal Service
(Revised August 2015)

REPORT/APPLICATION FOR RELIEF ON ACCOUNT OF LOSS, THEFT,
OR DESTRUCTION OF UNITED STATES BEARER SECURITIES
(ORGANIZATIONS)

OMB No. 1530-0034

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. Describe the securities in the spaces below.
TITLE OF SECURITY
(Identify by interest rate, title, call
and maturity dates)

SERIAL NUMBER

COUPONS ATTACHED

FACE AMOUNT

DATE ACQUIRED

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

OR

TAXPAYER IDENTIFICATION NUMBER:
(Social Security Number)

(Employer Identification Number)

,

2. My name and title are:

.

(Name)

(Title)

.

The complete name of the organization I represent is:
(Name of Organization)

The organization is:

.

a corporation organized under the laws of
a partnership.

.

The organization's principal office is at:
(Street and Number or Rural Route)

(City)

(State)

(ZIP Code)

(City)

(State)

(ZIP Code)

3. Is your organization the sole owner? Yes
No
If Yes, from whom were the securities acquired?
(Name)

(Street and Number or Rural Route)

If No, in what capacity is your organization acting and what is the owner's name and address?

(Capacity)

(Name)

(Street and Number or Rural Route)

(City)

Yes

4. Has your organization reimbursed the owner (wholly or in part) for the securities?
If Yes, furnish the amount of the reimbursement:

$

(State)

(ZIP Code)

No

.

Provide details of the reimbursement:
(Circumstances)

(Name of Payee)

(Street and Number or Rural Route)

(City)

(State)

(ZIP Code)

Yes

5. Has your organization been reimbursed for the loss (or does it expect to be)?
If Yes, furnish the amount of the reimbursement:

$

No

.

Provide details of the reimbursement:
(Circumstances)

Provide the name and address of the payer:
(Name of Payer)

(Street and Number or Rural Route)

(City)

(State)

(ZIP Code)

6. Were the securities:

•
•

Yes
Yes

Lost?
Stolen?

No
No

Date of theft:
Yes
No
If Yes, attach a copy of the report.
Was a police report filed?
Yes
No
(Send any remaining pieces with this form.)

•

Destroyed?

•

When was the loss discovered?

•

Who had the securities last, and why?

•

Who had access to the securities?

•

Where were the securities last placed?

•

When were the securities last seen?

•

What have you done to recover the securities?

• Tell us the names of any other persons having knowledge of the loss.
7. The undersigned owner or organization acting on behalf of the owner requests that the Secretary of the Treasury grant relief as authorized by
law, and if relief is granted, acknowledge that the original securities become the property of the United States. Upon the granting of relief, we
assign all our right, title, and interest in the original securities to the United States and bind ourselves, our heirs, executors, administrators,
successors and assigns, jointly and severally: (1) to surrender the original securities to the Department of the Treasury if they are recovered;
(2) to hold the United States harmless due to 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 to 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 the redemption. We consent to the release of any
information contained in this form, or regarding the securities described, to any party having an ownership or entitlement interest in these
securities.
We certify under penalty of perjury and severally affirm and say that the securities described on this form have been lost, stolen, or destroyed
and that the information given is true to the best of our knowledge and belief.

You must wait until you are in the presence of a certifying officer to sign this form.

(Exact name of Organization)

By:

Officer's Home
Address:

(Signature on behalf of Organization)

(Print Name and Title of Officer)

(Number and Street or Rural Route)

(E-Mail Address)

(City)

(State)

(ZIP Code)

(Daytime Telephone Number)

Certifying Officer – The individual 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 appeared before me this

day of

,
(Month)

,
(Year)

, and signed this form.

at
(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 1:
TITLE OF SECURITY
(Identify by interest rate, title, call
and maturity dates)

SERIAL NUMBER

FACE AMOUNT

COUPONS ATTACHED

DATE ACQUIRED

(If you need more space to describe your securities, use a continuation sheet and attach it to the form.)

3

INSTRUCTIONS
USE OF FORM – Do not use this form for United States Savings Bonds, Retirement Plan Bonds, or Individual Retirement Bonds.
Use this form to apply for relief on account of loss, theft, or destruction of United States bearer securities owned by or in
the custody of an organization at the time of the loss. A bond of indemnity will ordinarily be required, but only on a form
that will be provided, when necessary. The Secretary of the Treasury reserves the right to require additional evidence in
any particular case.
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.
ITEM 1.

Describe the securities. Provide as much information as possible. List coupons that were attached to the
securities, either by number or date. Show the owner's Social Security Number or the employer
identification number, if one has been assigned.

ITEM 2.

You must be an officer or a general partner to execute the application on behalf of your organization.
Provide your complete name and your official title. Check the box to indicate if your organization is a
corporation (indicate where the organization is incorporated) or a partnership. Provide the address of your
organization's principal office. If your organization is a corporation, complete a Certificate of Incumbency of
Officers on FS Form 1014.

ITEM 3.

Tell us if your organization is the owner of the securities by marking the appropriate box.

 If your organization is the owner, provide the name and address of the person from whom the securities
were acquired.

 If your organization is not the owner, tell us in what capacity your organization is acting; for example,
state if your organization is a broker acting on behalf of the owner. Insert the owner's complete name
and address in the spaces provided.
ITEM 4.

Check the appropriate box to show if your organization has reimbursed the owner, wholly or in part, for the
securities. If the answer is Yes, show the amount of the reimbursement, give details regarding the
circumstances, and provide the payee's name and address.

ITEM 5.

Show the total amount of reimbursement received or expected by your organization from any source. Give
the exact names of any insurance companies, rather than the names of agents. Provide any other
appropriate details and furnish the payer's name and address.

ITEM 6.

Check each box that applies. Provide complete details regarding the loss, theft, or destruction of the
securities. If another person had possession of the securities or knowledge of the circumstances of the
loss, that person must provide a separate statement on FS Form 2243, Supplemental Statement for United
States Securities, explaining the circumstances.

ITEM 7.

Show the name of your organization, sign the form in ink, print your name and title, and provide your
complete home address, daytime telephone number, and e-mail address, if applicable. Imprint your
organization's seal in the space provided or indicate that your organization does not have a seal.

CERTIFICATION – You 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 form and 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 Circular No. 300, 31 CFR 306.
WHERE TO SEND – Send the completed form, and any additional information or evidence, to the Department of the
Treasury, Bureau of the Fiscal Service, 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 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 55 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 the above address; send to the correct address shown in "WHERE TO SEND"
above.

4