U.S. SAVINGS BOND PAYROLL AUTHORIZATION
A0-F022A (5-06)
NEW
SECTOR DEPT/ZONE
CHANGE
TOTAL BOND DEDUCTION PER PAY PERIOD
PART A EMPLOYEE INFORMATION
EMPLOYEE NAME SOCIAL SECURITY NO.
.
EE Bonds reflect 50% of the face value of the savings bond. Purchase Price $ 50 100 250 500 Face Value $ 100 200 500 1000 DENOMINATIONS I Bonds reflect 100% of the face value of the savings bond. Purchase Price $ 50 75 100 200 500 Face Value $ 50 75 100 200 500 1000 1000
PART B BOND REQUEST
1
TYPE OF REQUEST
Purchase bond Deduct $ from each paycheck NOTE: The minimum weekly deduction amount is $1.00 Cancel EE bond and re-enroll in I bond Change bond denomination to $ Change weekly deduction from $ to $ Change name of owner as indicated Change co-owner or beneficiary as indicated Cancel participation in bond program
BOND TYPE EE Bond (Check one): I Bond No selection defaults to EE Bond
PURCHASE PRICE
OWNER'S SOCIAL SECURITY NO.
NOTE: Registered bonds will be sent to employee's mailing address. The purchaser may, if desired, designate a co-owner or beneficiary on the bond, but not both.
FIRST NAME
OWNER
MI
LAST NAME
FIRST NAME
CO-OWNER
MI
LAST NAME
SOC SEC NO.
FIRST NAME
BENEFICIARY
MI
LAST NAME
SOC SEC NO.
If request is for: single bond, ensure that Bond Request 1 is completed then go to Part C. multiple bonds, go to Bond Request 2.
2
TYPE OF REQUEST
Purchase bond Deduct $ from each paycheck NOTE: The minimum weekly deduction amount is $1.00 Cancel EE bond and re-enroll in I bond Change bond denomination to $ Change weekly deduction from $ to $ Change name of owner as indicated Change co-owner or beneficiary as indicated Cancel participation in bond program
BOND TYPE EE Bond (Check one): I Bond No selection defaults to EE Bond
PURCHASE PRICE
OWNER'S SOCIAL SECURITY NO.
NOTE: Registered bonds will be sent to employee's mailing address. The purchaser may, if desired, designate a co-owner or beneficiary on the bond, but not both.
FIRST NAME
OWNER
MI
LAST NAME
FIRST NAME
CO-OWNER
MI
LAST NAME
SOC SEC NO.
FIRST NAME
BENEFICIARY
MI
LAST NAME
SOC SEC NO.
3
TYPE OF REQUEST
Purchase bond Deduct $ from each paycheck NOTE: The minimum weekly deduction amount is $1.00 Cancel EE bond and re-enroll in I bond Change bond denomination to $ Change weekly deduction from $ to $ Change name of owner as indicated Change co-owner or beneficiary as indicated Cancel participation in bond program
BOND TYPE EE Bond (Check one): I Bond No selection defaults to EE Bond
PURCHASE PRICE
OWNER'S SOCIAL SECURITY NO.
NOTE: Registered bonds will be sent to employee's mailing address. The purchaser may, if desired, designate a co-owner or beneficiary on the bond, but not both.
FIRST NAME
OWNER
MI
LAST NAME
FIRST NAME
CO-OWNER
MI
LAST NAME
SOC SEC NO.
FIRST NAME
BENEFICIARY
MI
LAST NAME
SOC SEC NO.
PART C EMPLOYEE AUTHORIZATION
This authorization will continue in effect until cancelled by me, termination of my employment, or termination of the offering of these securities.
EMPLOYEE SIGNATURE WORK PHONE NO. DATE
(
NOTE:
)
Return completed form to one of the addresses below. Do not e-mail form. All forms without signatures will be returned. Payroll Service Center (East) Payroll Service Center (West) Z37-025 K06P21/V1