FS Form 5367 FHA Debenture Transfer Request

OMB No. 1530-0054

FHA DEBENTURE TRANSFER REQUEST

HUD ACCOUNT IDENTIFICATION

FOR DEPARTMENT USE

FROM: HUD ACCOUNT NUMBER
ENTERED BY

ACCOUNT NAME

APPROVED BY

DATE APPROVED

ADVICE NUMBER

DEBENTURE IDENTIFICATION AND AMOUNT
Transfer $

of my holdings for CUSIP

Transfer $

of my holdings for CUSIP

Transfer $

of my holdings for CUSIP

Transfer $

of my holdings for CUSIP

Transfer $

of my holdings for CUSIP

TRANSFER REQUESTED
TO: HUD ACCOUNT NUMBER
If no HUD account exists, the transferee must complete FS Form 5366, FHA New Account Request.
ACCOUNT NAME

Identify the HUD account to which you want your debentures transferred.

TAXPAYER IDENTIFICATION NUMBER (If available)

SOCIAL SECURITY NUMBER

or

EMPLOYER IDENTIFICATION NUMBER

SEE INSTRUCTIONS FOR PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE

FS Form 5367

Department of the Treasury | Bureau of the Fiscal Service

RESET
Revised February 2016

AUTHORIZATION
DO NOT SIGN THIS FORM UNTIL YOU ARE IN THE PRESENCE OF AN AUTHORIZED CERTIFYING INDIVIDUAL.
I SUBMIT THIS REQUEST PURSUANT TO THE PROVISIONS OF 31 CFR PART 306 AND 31 CFR PART 337.
UNDER PENALTIES OF PURJURY, I CERTIFY THAT THE INFORMATION PROVIDED ON THIS FORM IS TRUE, CORRECT
AND COMPLETE.

SIGNATURE(S)

DATE

TITLE (IF APPROPRIATE)

CERTIFICATION
YOUR SIGNATURE MUST BE CERTIFIED BY AN AUTHORIZED CERTIFYING INDIVIDUAL.
I CERTIFY THAT THE ABOVE-NAMED PERSON(S) AS DESCRIBED, WHOSE IDENTITY IS KNOWN OR PROVEN TO ME,
PERSONALLY APPEARED BEFORE ME THIS

DAY OF

AT

MONTH/YEAR

CITY/STATE

SIGNATURE AND TITLE OF CERTIFYING INDIVIDUAL
OFFICIAL SEAL
OR STAMP
(SUCH AS
CORPORATE SEAL,
SIGNATURE
GUARANTEED
STAMP, OR
MEDALLION STAMP).

NAME OF FINANCIAL INSTITUTION

ADDRESS

CITY/STATE

CERTIFICATION BY A NOTARY PUBLIC IS NOT ACCEPTABLE.

FS Form 5367

Department of the Treasury | Bureau of the Fiscal Service

Revised February 2016

INSTRUCTIONS FOR COMPLETING AN
FHA DEBENTURE TRANSACTION REQUEST
PURPOSE
You may use this form to request the transfer of debentures from one HUD account to another HUD account.
IMPORTANT NOTICES
This form cannot be used to transfer debentures to a financial institution.
Unless all the required information is provided legibly, there may be a delay in processing your request. To avoid delays, read the
instructions carefully and print clearly in ink only.

S/B HUD ACCOUNT INFORMATION
Print your HUD ACCOUNT NUMBER and the ACCOUNT NAME as stated on your HUD STATEMENT OF ACCOUNT.

DEBENTURE IDENTIFICATION AND AMOUNT
Complete one line per CUSIP number, indicating the dollar amount of debentures to be transferred. THE AMOUNT TO BE TRANSFERRED
AND THE AMOUNT REMAINING IN THE CUSIP MUST SATISFY THE MINIMUM HOLDING REQUIREMENTS FOR THE DEBENTURE.

TRANSACTIONS REQUESTED
Provide the HUD ACCOUNT NUMBER, ACCOUNT NAME and if available, the taxpayer identification number of the account to which
the debentures are to be transferred.

AUTHORIZATION
Sign and date the request in the presence of an authorized certifying individual. Identification may be required. Remember, if there
are two owners joined by the word “and”, both must sign.

CERTIFICATION
Certification of your signature is required. Acceptable certifying individuals include authorized employees of insured depository
institutions and corporate central credit unions. Certification by a notary public is not acceptable.
SUBMISSION
Submit this request to:

Bureau of the Fiscal Service
Special Investments Branch
200 Third Street
P.O. Box 396
Parkersburg, WV 26102-0396

Telephone Number: (304) 480-5299
Fax Number: (304) 480-5277
E-Mail Address: opda-sib@fiscal.treasury.gov

CONFIRMATION OF THE TRANSFER
You will receive a HUD STATEMENT OF ACCOUNT after your debentures have been transferred.
NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
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 Fiscal Service, Forms Management Officer, Parkersburg,
WV 26106-1328. DO NOT SEND completed form to this address; send to the correct address shown in the instructions.

FS Form 5367

Department of the Treasury | Bureau of the Fiscal Service

Revised February 2016