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Customer Name
Case No.
FS Form 1025
Department of the Treasury
Bureau of the Fiscal Service
(Revised March 2018)
OMB No. 1530-0029
CLAIM FOR LOST, STOLEN, OR DESTROYED
UNITED STATES REGISTERED SECURITIES
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
REGISTRATION
(Exact inscription on each security)
FACE AMOUNT
(If you need more space to describe your securities, use the continuation sheet on page 3.)
-
TAXPAYER IDENTIFYING NUMBER:
-
-
OR
(Social Security Number)
(Employer Identification Number)
2. Are you the present lawful owner of the securities in your own right? Yes
If you are not the owner, in what capacity are you acting?
No
3. Were the securities ever assigned, endorsed, or transferred in any manner? Yes
If Yes, to whom? (Give name, address, and other details.)
No
4. Were the securities:
Lost?
Stolen?
Yes
No
Yes
No
Date of theft:
Was a police report filed?
Yes
No
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?
Were any identification documents also lost or stolen?
Yes
No
If Yes, attach a copy of the report.
(Send any remaining pieces with this form.)
Yes
No
If Yes, please list them.
No
If Yes, please explain fully, and include the name
Have you received reimbursement because of the loss? Yes
and address of the person or firm making reimbursement, the amount of the reimbursement, and the details of any court
proceedings pending or contemplated.
What have you done to recover the securities?
Tell us the names of any other persons having knowledge of the loss.
5. If you have been appointed legal representative (see Item 5 in the Instructions):
What is your legal capacity?
Are you court-appointed?
Yes
No
6. If a minor is named on the securities:
What is his/her age?
What is your relationship to the minor?
What is his/her social security number?
7. We severally petition the Secretary of the Treasury for 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.
Sign here:
Sign here:
(Signature)
(Signature)
(Number and Street or Rural Route)
(Number and Street or Rural Route)
(City)
(State)
(Social Security Number)
OR
(ZIP Code)
(City)
(Employer Identification Number)
(State)
(Social Security Number)
OR
(ZIP Code)
(Employer Identification Number)
(Daytime Telephone Number)
(Daytime Telephone Number)
(E-Mail Address)
(E-Mail Address)
Certifying Officer – The individuals must sign in your presence. Complete the certification and affix your stamp or seal.
I CERTIFY that
I CERTIFY that
whose identity is known or was proven to me, personally
whose identity is known or was proven to me, personally
appeared before me this
day of
,
appeared before me this
day of
(Month)
,
, at
(Year)
(City)
,
, at
(State)
(Year)
and signed this form.
(City)
(State)
and signed this form.
(Signature of Certifying Officer)
(OFFICIAL STAMP
OR SEAL)
,
(Month)
(Signature of Certifying Officer)
(OFFICIAL STAMP
OR SEAL)
(Title of Certifying Officer)
(Address)
(Title of Certifying Officer)
(Address)
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Continuation of description of securities in Item 1:
TITLE OF SECURITY
(Identify by interest rate, title, call
and maturity dates)
SERIAL NUMBER
FACE AMOUNT
REGISTRATION
(Exact inscription on 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
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 registered securities and registered
securities for which the Treasury Department acts as transfer agent. A bond of indemnity will ordinarily be required for
transferable securities 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
continuation sheet of paper and attach it to this form.
ITEM 1.
Describe the securities. Provide as much information as possible. Show the owner's social security number or
the employer identification number, if one has been assigned.
ITEM 2.
Tell us if you are the owner of the securities by marking the appropriate box. If you are not the owner, tell us the
capacity in which you are acting. If you have been appointed legal representative, see Item 5 for further
information and/or evidence required to support your application.
ITEM 3.
Tell us if the securities have ever been assigned, endorsed, or transferred by marking the appropriate box. If so,
furnish the name, address, and any other details regarding the person to whom the securities were assigned,
endorsed, or transferred.
ITEM 4.
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 explaining the circumstances.
ITEM 5.
If you were appointed as legal representative because:
the owner is deceased (with no surviving coowner or beneficiary named on the securities), or
the owner or coowner is a minor, or
the owner or coowner is incapacitated,
complete the form and submit a court certificate or certified copy of your letters of appointment, under court seal,
showing the appointment is still in full force.
If your name and official capacity are shown in the registration of the securities, evidence of your
appointment is not necessary.
If no legal representative has been appointed for a deceased or incompetent owner, advise the
Bureau of the Fiscal Service and additional instructions will be provided.
ITEM 6.
If a minor is named on the securities, show the minor's age and social security number, and tell us your
relationship to the minor.
ITEM 7.
Sign the form in ink, print your name, and provide your address, daytime telephone number, and e-mail address,
if applicable. Your signature must be certified (see CERTIFICATION below).
CERTIFICATION – You must appear before and establish identification to the satisfaction of an authorized certifying officer or
other officer authorized by law to administer oaths and sign the form in the presence of the officer. The certifying officer must
complete the certification forms provided and affix the seal or stamp 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, current revision, 31 CFR 306.
WHERE TO SEND – Send the completed form, and any additional information or evidence, to Treasury Retail Securities Site,
PO Box 9150, Minneapolis, MN 55480-9150.
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" in the Instructions.
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| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |