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PD F 5179 E
Department of the Treasury
Bureau of the Public Debt
(Revised November 2012)
Legacy Treasury Direct®
OMB No. 1535-0069
www.treasurydirect.gov
800-722-2678 SEE INSTRUCTIONS -TYPE OR PRINT IN INK ONLY - NO ALTERATIONS OR CORRECTIONS
1. Legacy Treasury Direct ACCOUNT INFORMATION FOR DEPARTMENT USE
DOCUMENT AUTHORITY
APPROVED BY
DATE APPROVED
Legacy Treasury Direct ACCOUNT NUMBER:
ACCOUNT NAME
2. SECURITIES IDENTIFICATION AND AMOUNT CHECK THE BOXES WHICH APPLY AND PROVIDE THE INFORMATION REQUESTED.
Transfer ALL my securities for the above Legacy Treasury Direct account.
Transfer my securities totaling $ from the CUSIPs below. (Additional forms are required for more than 10 CUSIPs.)
CUSIP AMOUNT Department Use
Reference Number CUSIP AMOUNT Department Use
Reference Number
$ $
$ $
$ $
$ $
$ $
Transfer $ of my holdings for CUSIP number
(If you are NOT transferring all of your holdings for this CUSIP, you must also list the specific sub-accounts and amounts to be transferred
below. This information is shown on your Legacy Treasury Direct Statement of Account.)
SUB-ACCOUNT AMOUNT SUB-ACCOUNT AMOUNT SUB-ACCOUNT AMOUNT
$ $ $
3. TRANSFER INSTRUCTIONS CHECK ONE BOX ONLY AND PROVIDE THE INFORMATION REQUESTED FOR THE TRANSFER.
INTERNAL TRANSFER TO ANOTHER Legacy Treasury Direct ACCOUNT NUMBER
Legacy Treasury Direct ACCOUNT NUMBER
NOTE: This must be an existing
account; new accounts aren’t available.
ACCOUNT NAME
Identify the Legacy
Treasury Direct account
to which you want your
securities transferred.
TAXPAYER IDENTIFICATION NUMBER (IF AVAILABLE)
First-Named OR
Owner Social Security Number Employer Identification Number
TRANSFER TO AN ESTABLISHED ONLINE TreasuryDirect ACCOUNT NUMBER
TreasuryDirect ACCOUNT NUMBER (May be established at www.treasurydirect.gov.)
ACCOUNT NAME
Identify the
TreasuryDirect account to
which you want your
securities transferred.
TAXPAYER IDENTIFICATION NUMBER (IF AVAILABLE)
First-Named OR
Owner Social Security Number Employer Identification Number
SECURITY TRANSFER REQUESTPD F 5179 E 2
EXTERNAL TRANSFER TO A FINANCIAL INSTITUTION (Before completing, see instructions.)
ROUTING NUMBER:
FINANCIAL INSTITUTION WIRE NAME:
AGENT/BROKER NAME:
AGENT/BROKER PHONE NUMBER:
SPECIAL HANDLING INSTRUCTIONS:
4. AUTHORIZATION YOU MUST WAIT UNTIL YOU ARE IN THE PRESENCE OF A CERTIFYING OFFICER TO SIGN THIS FORM. IF
THERE ARE TWO OWNERS JOINED BY THE WORD “AND,” BOTH MUST SIGN.
I/We submit this transfer request pursuant to the provisions of Department of the Treasury Circulars, Public Debt Series Nos. 2-86
(31 CFR Part 357) and 1-93 (31 CFR Part 356).
Under penalties of perjury, I/we certify that the information provided on this form is true, correct, and complete.
Signature Title (if appropriate)
Signature Title (if appropriate)
Address Telephone (Daytime)
5. CERTIFICATION YOUR SIGNATURE MUST BE CERTIFIED BY AN AUTHORIZED CERTIFYING OFFICER.
Instructions to Certifying Officer:
1. Name of person(s) who appeared and date/place 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(ies) is/are known or proven to me,
Name(s) of Person(s) Who Appeared
personally appeared before me this day of in the year
Month Year
at , and signed this request.
City / State
Signature and Title of Certifying Officer
Name of Financial Institution
ACCEPTABLE CERTIFICATIONS:
Financial Institution's Official Seal or Stamp
(such as Corporate Seal, Signature Guaranteed
Stamp, or Medallion Stamp). Brokers must
use a Medallion Stamp.
Address
City / State / ZIP Code
Telephone
Certification by a Notary is NOT Acceptable.
PD F 5179 E 3 PD F 5179 E Department of the Treasury Bureau of the Public Debt (Revised November 2012) www.treasurydirect.gov 800-722-2678 Legacy Treasury Direct® INSTRUCTIONS FOR COMPLETING A SECURITY TRANSFER REQUEST PURPOSE You may use this form to request the transfer of securities from a Legacy Treasury Direct account to: another Legacy Treasury Direct account, or an online TreasuryDirect account, or a designated account at a financial institution. IMPORTANT NOTICES This form must be signed. Only original signatures and forms will be accepted (stamped signatures are not acceptable). Unless all the required information is prov ided legibly, there may be a delay in processing your request. To avoid delays, read the instructions carefully and print clearly in ink only. TRANSFER REQUESTS WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS. 1. Legacy Treasury Direct ACCOUNT INFORMATION Print your Legacy Treasury Direct ACCOUNT NUMBER and the ACCOUNT NAME (registration) as stated on your Legacy Treasury Direct STATEMENT OF ACCOUNT. 2. SECURITIES IDENTIFICATION AND AMOUNT Check the boxes which apply and provide the information requested. ALL REQUIRED INFORMATION IS LISTED ON YOUR Legacy Treasury Direct Statement of Account. To transfer ALL the securities in the Legacy Treasury Direct account listed in Section 1, check the first box. To transfer one or more securities in your Legacy Treasury Direct account, check the second box, enter the total dollar amount of the securities being transferred, and list the CUSIP numbers and amounts. AMOUNT - The total par for the CUSIP. CUSIP - The number (for example, 912795XXX) that identifies the securities to be transferred (located under the heading “Security” on your Statement of Account). To transfer a portion of one security in your Legacy Treasury Direct account, check the third box, enter only the amount being transferred, and list the CUSIP number. To transfer security sub-account(s), enter the sub-account number(s) and dollar amount(s) to be transferred. THE AMOUNT TO BE TRANSFERRED AND THE AMOUNT REMAINING IN THE CUSIP MUST SATISFY BOTH THE MINIMUM AND MULTIPLE HOLDING REQUIREMENTS FOR THE SECURITY. 3. TRANSFER INSTRUCTIONS (Choose One Option Only) INTERNAL TRANSFER TO ANOTHER Legacy Treasury Direct ACCOUNT Check the box to transfer your securities to another Legacy Treasury Direct account number. The transfer must be to an existing account; new accounts aren’t available. Legacy Treasury Direct ACCOUNT NUMBER - Enter the number of t he account to which the securities are being transferred. ACCOUNT NAME - Enter the ACCOUNT NAME (registration ) as shown on the transferee’s Statement of Account. TAXPAYER IDENTIFICATION NUMBER - If available, enter the TAXPAYER IDENTIFICATION NUMBER used on the account to which the securities are to be transferred. TRANSFER TO AN ONLINE TreasuryDirect ACCOUNT Check the box to transfer your securities to an online TreasuryDirect account number. TreasuryDirect ACCOUNT NUMBER - Enter the number of the acco unt to which the securities are being transferred. If a new account has not yet been established, you can establish one at www.treasurydirect.gov. ACCOUNT NAME - Enter the ACCOUNT NAME (registrati on) as shown on the online TreasuryDirect account. TAXPAYER IDENTIFICATION NUMBER - If available, enter the TAXPAYER IDENTIFICATION NUMBER used on the account to which the securities are to be transferred.
PD F 5179 E 4 EXTERNAL TRANSFER TO A FINANCIAL INSTITUTION Check the box to transfer your securities to a financial institution for safekeeping or sale. Contact the financial institution for their “Book- Entry” delivery instructions. Please note: Securities CANNOT be transferred to a checking or savings account. Provide the following information: ROUTING NUMBER - ABA (identification) number of t he financial institution receiving the securities. FINANCIAL INSTITUTION WIRE NAME - Prov ide the financial institution’s “Book-Entry” delivery instructions. Instructions include the receiving bank’s name and safekeeping account number OR the receiving bank’s name and the brokerage firm’s name (these must be in the approved telegraphic abbreviation “short” form). AGENT/BROKER NAME AGENT/BROKER PHONE NUMBER SPECIAL HANDLING INSTRUCTIONS - The customer name and ac count number at the financial institution for delivery of securities; any other instructions required by your financial institution. Examples: To a financial institution for safekeeping: To a financial institution for transfer to a brokerage firm: Routing Number: XXXXXXXXX Routing Number: XXXXXXXXX Financial Institution Wire Name: ABC BK/TRUST Financial Institution Wire Name: ABC/CUST/BRKG Special Handling Instructions: FURTHER CREDIT TO JOHN DOE TRUST ACCOUNT NUMBER XXXXXX Special Handling Instructions: FURTHER CREDIT TO JOHN DOE BROKERAGE ACCOUNT NUMBER XXXXXX 4. AUTHORIZATION Sign the request in the presence of an authorized certifying officer. Identification may be required. Remember, if there are two owners joined by the word “and,” both must sign (for example, John Doe and Mary Doe). Please provide an address and daytime telephone number (including area code) where you may be contacted if there are questions about this transfer. 5. CERTIFICATION Certification of your signature is required. Acceptable certifying officers include authorized employees of insured depository institutions and corporate central credit unions. Brokers must use a medallion stamp. Certification date and address of financial institution or broker is required. Please note: Certification by a notary public is NOT acceptable. Sample certification for a financial institution: SIGNATURE GUARANTEED ABC National Bank Hillview Branch _________________________________ Authorized Signature Acceptable certification for a brokerage: SIGNATURE GUARANTEED MEDALLION GUARANTEED Generic Brokerage _________________________________ Authorized Signature XXXXXXXX SECURITIES TRANSFER AGENTS MEDALLION PROGRAM [Bar Code] WHERE TO SEND Please mail your form to the appropriate address below. • If requesting a transfer to another Legacy Treasury Direct account or to a financial institution: Treasury Retail Securities Site, PO Box 9150, Minneapolis, MN 55480-9150 • If requesting a transfer to an online TreasuryDirect account: Bureau of the Public Debt, PO Box 7015, Parkersburg, WV 26106-7015 This form must be received at least ten business days in advance of: • the maturity date of the security to ensure processing, and • an interest payment date for the security to ensure processing prior to that date. CONTACT Call us toll-free in the United States at 800-722-2678. Outside the U.S.? Call us at 304-480-6464. CONFIRMATION OF THE TRANSFER You will receive a Legacy Treasury Direct Statement of Account after your securities have been transferred. Under certain circumstances, there may be a hold on the account and a statement won’t be mailed. NOTICE UNDER THE PRIVACY ACT AND PAPERWORK REDUCTION ACT The collection of the information you are requested to provide on this form is authorized by 31 U.S.C. Ch. 31 relating to the p ublic debt of the United States. The furnishing of a Social Security Number, if requested, is also required by Section 6109 of the Internal Revenue Code (26 U.S.C. 6109). The purpose of requesting the information is to enable the Bureau of the Public Debt and its agents to issue securities, proces s transactions, make payments, identify owners and their accounts, and provide reports to the Internal Revenue Service. Furnishing the information is voluntary; however, without the in formation Public Debt may be unable to process transactions. Information concerning securities holdings and transactions is considered confidential under Treasury regulations (31 CFR, Part 323) and the Privacy Act. This information may be disclosed to a law enforcement agency for investigation purposes; courts and counsel for litigation purposes; others entitled t o distribution or payment; agents and contractors to administer the public debt agencies or entities for debt collection or to obtain current addresses for payment; agencies through approved computer matches; Congressional offices in response to an inquiry by the individual to whom the record pertains; as otherwise authorized by law or regulation. We estimate it will take you about 10 minutes to complete this form. However, you are not required to provide information reque sted unless a valid OMB control number is displayed on the form. Any comments or suggestions regarding this form should be sent to the Bureau of the Public Debt, Forms Management Officer , Parkersburg, WV 26106-1328. DO NOT SEND completed form to this address; send to the appropriate address shown in “WHERE TO SEND” in the Instructions.