TAILIEUCHUNG - DISPOSITION OF TREASURY SECURITIES BELONGING TO A DECEDENT’S ESTATE BEING SETTLED WITHOUT ADMINISTRATION

If you have a bond dispute if is important to have evidence to show you have met your obligations as a tenant or resident. You can also request copies of evidence from the other party regarding their claims against your bond. You can ask the lessor, agent or provider to give you copies of any receipts or other evidence they are relying on to justify their claims against you. If you are not given this information you can request copies of this evidence during the RTA conciliation process. If you believe the lessor or provider does not have a good reason to claim all or part of your bond,. | RESET For official use only Customer Name Customer No. PD F 5336 E OMB No. 1535-0118 Department of the Treasury UIOIUOIIIUN Ur iREnvURT olcUriiieo DELUNUINU IU A UEcEUENi S Bureau Ofthe PUblic Debt y ESTATE BEING SETTLED WITHOUT ADMINISTRATION Revised December 2010 Visit us on the Web at 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 UR TYPE ALL INFORMATION A person qualified by the Department of the Treasury to act as voluntary representative must use this form to request disposition of United States Treasury Securities and or related payments belonging to a decedent s estate that is not being administered. See the instructions for the definition of a voluntary representative. If the decedent s securities and or related payments are worth over 100 000 redemption and or par value as of the date of death Treasury regulations require that the estate be administered through the court in this event this form may not be used. WHERE TO SEND - Unless otherwise instructed in accompanying correspondence send this form all securities and or related checks and any necessary evidence to Department of the Treasury Bureau of the Public Debt using the appropriate address below For a request involving only definitive paper savings bonds - PO Box 7012 Parkersburg WV 26106-7012 For any other request related to this form - PO Box 426 Parkersburg WV 26106-0426 Carefully read the instructions before completing this form. PART A - ESTATE INFORMATION Provide the information below and submit certified copies of the death certificates for all deceased registrants. Name of Deceased Owner - If more than one person named on the securities the person who died last Decedent s Social Security Number Jurisdiction of Legal Residence By signing this form I certify that a legal .

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