Request by Fiduciary for Reissue - fs form 1455 pdf

---

• (1) treasurydirect form 1522
• (2) treasurydirect fs form 1455
• (3) fs form 1455 treasury
• (4) treasurydirect gov forms

RESET
For official use only:
Customer Name Case Number
FS Form 1455 (revised June 2017) OMB No. 1530-0035
Request by Fiduciary for Distribution of
United States Treasury 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
One or more fiduciaries (individual or corporate) must use this form to request distribution of United States Treasury Securities to the
person lawfully entitled due to distribution of a trust or an estate or other reasons set out in the instructions.
Part A - Reason for Distribution
I/We request distribution of the securities and/or related payments for the following reason:
Distribution of an estate OR trust to person(s) entitled
Other reason for distribution:
If a person entitled to paper savings bonds (Series EE, E, I, HH, or H) wants . . .
. . . payment, they must submit FS Form 1522
. . . reissue to themselves, they must submit FS Form 4000 For forms, go to
. . . reissue to a trust, they must submit FS Form 1851 www.treasurydirect.gov.
A person entitled to electronic securities held in TreasuryDirect must submit FS Form 5446.
Part B - Distribution of Securities
I/We request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)
(Social Security Number or Employer Identification Number) (Telephone Number)
(Address)
2. Description of securities and/or related payments:
Title of Security Issue Face Amount Identifying Number Registration
Date
NOTE: Individual savings bonds (Series EE, E, I, HH, and H) may not be split. Each savings bond must be distributed, in its entirety, to
an entitled individual or entity. Marketable securities may be distributed in full or in increments of $100.
If you want to split a marketable security, describe the exact amount of the distribution:
FS Form 1455 Department of the Treasury | Bureau of the Fiscal Service 1
Part B - Distribution of Securities (Continued)
I/We request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)
(Social Security Number) OR (Employer Identification Number)
(Address and Telephone Number)
2. Description of securities:
Title of Security Issue
Date Face Amount Identifying Number Registration
NOTE: Individual savings bonds (Series EE, E, I, HH, and H) may not be split. Each savings bond must be distributed, in its entirety, to
an entitled individual or entity. Marketable securities may be distributed in full or in increments of $100.
If you want to split a marketable security, describe the exact amount of the distribution:
I/We request that the securities and/or related payments be distributed as follows:
1. Distribute to:
(Name)
(Social Security Number) OR (Employer Identification Number)
(Address and Telephone Number)
2. Description of securities:
Title of Security Issue Face Amount Identifying Number Registration
Date
NOTE: Individual savings bonds (Series EE, E, I, HH, and H) may not be split. Each savings bond must be distributed, in its entirety, to
an entitled individual or entity. Marketable securities may be distributed in full or in increments of $100.
If you want to split a marketable security, describe the exact amount of the distribution:
FS Form 1455 Department of the Treasury | Bureau of the Fiscal Service 2
Part C - Signatures and Certifications
I/We certify under penalty of perjury that the information provided herein is true and correct to the best of my/our knowledge
and belief, and agree to distribution of the securities as indicated in Part B. I/We bind ourselves, our heirs, legatees, successors
and assigns, jointly and severally, to hold the United States harmless on account of the transaction requested, and to indemnify
unconditionally and promptly repay the United States in the event of any loss which results from this request, including interest,
administrative costs, and penalties. I/We consent to the release of any information regarding this transaction, including information
contained in this form, to any party having an ownership or entitlement interest in the securities or payments.
You must wait until you are in the presence of a certifying officer to sign this form.
Sign Here:
(Signature)
(Applicant's Title)
(Number and Street, Rural Route, or PO Box) (City) (State) (ZIP Code)
(Daytime Telephone Number) (E-Mail Address)
Instructions to Certifying Officer:
1. Name of person(s) who appeared and date of appearance MUST be completed.
2. Medallion stamps require an original signature.
3. Person(s) must sign in your presence.
I certify that , whose identity is known or
(Name of Person Who Appeared)
proven to me, personally appeared before me this day of ,
(Month/Year)
at , and signed this form.
(City, State)
(Signature and Title of Certifying Officer)
(Name of Financial Institution)
(OFFICIAL STAMP
OR SEAL) (Address)
(City, State, ZIP Code)
(Telephone)
FS Form 1455 Department of the Treasury | Bureau of the Fiscal Service 3


What is the FS form 1522 for retirement? FS Form 1522 Department of the Treasury | Bureau of the Fiscal Service 1. FS Form 1522. (Revised February 2019) OMB No. 1530-0028. Special Form of Request for Payment of United States Savings and Retirement Securities Where Use of a Detached Request Is Authorized. IMPORTANT: Follow instructions in filling out this form.

• FS Form 1851 Request to Reissue United States Savings …
• FS Form 5394 Agreement and Request for Disposition of a …
• FS Form 1851 Request to Reissue United States Savings …
• Savings Bonds—Redemption and Reissue …
• FS Form 1455 Request by Fiduciary …