TAILIEUCHUNG - CLAIM FOR UNITED STATES SAVINGS BONDS NOT RECEIVED

If the lessor, agent or provider wants to claim all or part of your bond, and you do not agree, you should fi ll in your own Refund of Rental Bond and lodge it with the RTA as soon as possible. You should also contact the lessor, agent or provider to seek details about their claim and try to negotiate an agreement. If you later reach an agreement about the bond, you can both fi ll in and sign a new Refund of Rental Bond form to immediately release the bond. If you receive a Notice of Claim from the RTA, it means that the lessor, agent or. | CSE For official use only Customer Name Customer No. PD F 3062-4 E Department of the Treasury Bureau of the Public Debt OMB No. 1535-0098 CLAIM FOR UNITED STATES SAVINGS BONDS NOT RECEIVED Revised March 2011 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 I We the undersigned certify that the United States Savings Bonds described on this form have not been received either by me us or by anyone on my our behalf. If the addressee has moved since the bonds were mailed I we also certify that an inquiry was made at the former address. 1. DESCRIPTION OF BONDS - Describe the missing bonds in the spaces below. If you don t know the bond serial numbers provide as much information as possible and also indicate the total number of bonds that are missing. ISSUE DATE If you don t know the exact date furnish a range of issue dates. FACE AMOUNT BOND NUMBER INSCRIPTION Provide complete Social Security Number for example 123-456789 names including middle names or initials and addresses on the bonds. If you need more space to describe your bonds use a continuation sheet and attach it to this form. 2. DETAILS OF THE PURCHASE - Provide all requested information. Who purchased the bonds _ Purchaser s Name Purchaser s Social Security Number 3. AUTHORITY - Provide details regarding your authority to complete a claim for the bonds. Are you named on the bonds I I Yes I I No If Yes skip to Item 4. If No provide the following information Describe your authority _ parent guardian conservator legal representative administrator executor purchaser etc. Are you court appointed

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• Closing Costs
• Refinancing
• Clinical Course
• Survival
• Endoscopic Management
• Palliative Therapy
• costs
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• gap
• education
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• selling land
• real estate investment
• housing sales skills
• cost of the purchase price
• real estate
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