Appendix C
Forms and Informational Packets Pertinent to
U.S. Savings Bonds/Notes
Forms are available from your servicing Treasury Retail Securities site and may be downloaded from http://www.treasurydirect.gov.
The forms are also shown on the pages indicated in parentheses.
*FA 400 (page C-2) PD F 1980 E (page C-28) *PD F 5374 (page C-55)
Request for Reissue or Refund of Purchase Change of Address and/or Identification of Series I Order for U.S. Savings
Price Due to Error in Issue or in Registration Account for United States Registered Securities Bonds
of United States Savings Bonds
PD F 2513 E (page C-30) *PD F 5374-1 (page C-57)
PD F 385 (page C-6) Application by Voluntary Guardian of Series I Order for U.S. Savings
Certificate of Identity Incapacitated Owner of United States Savings Bonds to be Registered in Name
Bonds/Notes of Fiduciary
PD F 1048 E (page C-7)
Claim for Lost, Stolen, or Destroyed United PD F 2966 E (page C-34) PD F 5394 E (page C-59)
States Savings Bonds Special Bond of Indemnity by Purchaser of Agreement and Request for
United States Savings Bonds/Notes Involved in Disposition of a Decedent’s
PD F 1455 E (page C-13) a Chain Letter Scheme Treasury Securities
Request By Fiduciary For Distribution Of
United States Treasury Securities PD F 4000 E (page C-36) PD F 5396 E (page C-67)
Request to Reissue United States Savings Bonds Direct Deposit Sign-up Form
PD F 1522 E (page C-18)
Special Form of Request for Payment of PD F 5257 E (page C-43)
United States Savings and Retirement Change of Address Notification for HH/H
Securities Where Use of a Detached Request Accounts
Is Authorized (Limited use form - must be
obtained from TRS on a case basis) *PD F 5263 (page C-44)
Order for Series EE U.S. Savings Bonds
PD F 1849 E (page C-22)
Disclaimer and Consent With Respect to *PD F 5263-1 (page C-46)
United States Savings Bonds/Notes Order for Series EE U.S. Savings Bonds to be
Registered in Name of Fiduciary
PD F 1851 E (page C-24)
Request to Reissue United States Savings PD F 5336 E (page C-48)
Bonds to a Personal Trust Disposition Of Treasury Securities Belonging To
A Decedent’s Estate Being Settled Without
*Forms not available online. Administration
Informational packets are provided to agents and customers through a Treasury Retail Securities site when the savings
bond transaction must be forwarded to Public Debt for processing. Transactions that require forwarding to Public Debt
include cases specific to a nonadministered estate, power of attorney, trust, or claim transaction (other than non-receipt).
The packets are shown on the pages indicated in parentheses.
Nonadministered Estates Packet (page C-68) Power of Attorney Packet (page C-70) Trust Packet (page C-71)
Claim Packet (page C-73)
C-1
Sample 1 FA 400-M (Page 1 of 2)
Note: The FA 400-M is used by savings bonds agents who submit their savings bonds transactions
to the Minneapolis Treasury Retail Securities Site.
C-2
Sample 1 FA 400-M (Page 2 of 2)
C-3
Sample 2 FA 400-P (Page 1 of 2)
Note: The FA 400-P is used by savings bonds agents who submit their savings bonds transactions
to the Pittsburgh Treasury Retail Securities Site.
C-4
Sample 2 FA 400-P (Page 2 of 2)
C-5
Sample PD F 0385 E
C-6
Sample PD F 1048 E (Page 1 of 6)
C-7
Sample PD F 1048 E (Page 2 of 6)
C-8
Sample PD F 1048 E (Page 3 of 6)
C-9
Sample PD F 1048 E (Page 4 of 6)
C-10
Sample PD F 1048 E (Page 5 of 6)
C-11
Sample PD F 1048 E (Page 6 of 6)
C-12
Sample PD F 1455 E (Page 1 of 5)
C-13
Sample PD F 1455 E (Page 2 of 5)
C-14
Sample PD F 1455 E (Page 3 of 5)
C-15
Sample PD F 1455 E (Page 4 of 5)
C-16
Sample PD F 1455 E (Page 5 of 5)
C-17
Sample PD F 1522 E (Page 1 of 4)
C-18
Sample PD F 1522 E (Page 2 of 4)
C-19
Sample PD F 1522 E (Page 3 of 4)
C-20
Sample PD F 1522 E (Page 4 of 4)
C-21
Sample PD F 1849 E (Page 1 of 2)
C-22
Sample PD F 1849 E (Page 2 of 2)
C-23
Sample PD F 1851 E (Page 1 of 4)
C-24
Sample PD F 1851 E (Page 2 of 4)
C-25
Sample PD F 1851 E (Page 3 of 4)
C-26
Sample PD F 1851 E (Page 4 of 4)
C-27
Sample PD F 1980 E (Page 1 of 2)
C-28
Sample PD F 1980 E (Page 2 of 2)
C-29
Sample PD F 2513 E (Page 1 of 4)
C-30
Sample PD F 2513 E (Page 2 of 4)
C-31
Sample PD F 2513 E (Page 3 of 4)
C-32
Sample PD F 2513 E (Page 4 of 4)
C-33
Sample PD F 2966 E (Page 1 of 2)
C-34
Sample PD F 2966 E (Page 2 of 2)
C-35
Sample PD F 4000 E (Page 1 of 7)
C-36
Sample PD F 4000 E (Page 2 of 7)
C-37
Sample PD F 4000 E (Page 3 of 7)
C-38
Sample PD F 4000 E (Page 4 of 7)
C-39
Sample PD F 4000 E (Page 5 of 7)
C-40
Sample PD F 4000 E (Page 6 of 7)
C-41
Sample PD F 4000 E (Page 7 of 7)
C-42
Sample PD F 5257 E
C-43
Sample PD F 5263 (Page 1 of 2)
C-44
Sample PD F 5263 (Page 2 of 2)
C-45
Sample PD F 5263-1 (Page 1 of 2)
C-46
Sample PD F 5263-1 (Page 2 of 2)
C-47
Sample PD F 5336 E (Page 1 of 7)
C-48
Sample PD F 5336 E (Page 2 of 7)
C-49
Sample PD F 5336 E (Page 3 of 7)
C-50
Sample PD F 5336 E (Page 4 of 7)
C-51
Sample PD F 5336 E (Page 5 of 7)
C-52
Sample PD F 5336 E (Page 6 of 7)
C-53
Sample PD F 5336 E (Page 7 of 7)
C-54
Sample PD F 5374 (Page 1 of 2)
C-55
Sample PD F 5374 (Page 2 of 2)
C-56
Sample PD F 5374-1 (Page 1 of 2)
C-57
Sample PD F 5374-1 (Page 2 of 2)
C-58
Sample PD F 5394 E (Page 1 of 8)
C-59
Sample PD F 5394 E (Page 2 of 8)
C-60
Sample PD F 5394 E (Page 3 of 8)
C-61
Sample PD F 5394 E (Page 4 of 8)
C-62
Sample PD F 5394 E (Page 5 of 8)
C-63
Sample PD F 5394 E (Page 6 of 8)
C-64
Sample PD F 5394 E (Page 7 of 8)
C-65
Sample PD F 5394 E (Page 8 of 8)
C-66
Sample PD F 5396 E
Note: This form may be used in lieu of form SF 1199A.
C-67
Nonadministered Estates Packet (Page 1 of 2)
C-68
Nonadministered Estates Packet (Page 2 of 2)
C-69
Power of Attorney Packet (Page 1 of 1)
C-70
Trust Packet (Page 1 of 2)
C-71
Trust Packet (Page 2 of 2)
C-72
Claim Packet (Page 1 of 1)
C-73