PD F 1522 Sav1522
User Manual: 1522
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For official use only: Customer Name Case Number FS Form 1522 (revised December 2017) OMB No. 1530-0028 Special Form of Request for Payment of United States Savings and Retirement Securities Where Use of a Detached Request Is Authorized 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. 1. DESCRIPTION OF BONDS I am the owner or person entitled to payment of the securities described below, which bear the name(s) of . ISSUE DATE SERIAL NUMBER ISSUE DATE SERIAL NUMBER ISSUE DATE SERIAL NUMBER (If you need more space, attach either FS Form 3500 [see www.treasurydirect.gov], a plain sheet of paper, or a photocopy of this section.) 2. REQUEST FOR PAYMENT A Taxpayer Identification Number must be provided for the payee: (Social Security Number of Payee) OR (Employer Identification Number of Payee) 3. DELIVERY INSTRUCTIONS (Read Item 3 in the Instructions before completing this section.) Please deposit my funds directly, as authorized below: (Name/Names on the Account) Type of Account: Checking Savings (Depositor's Account No.) Bank Routing No. (nine digits): (Financial Institution's Name) FS Form 1522 Department of the Treasury | Bureau of the Fiscal Service (Phone No.) 1 4. SIGNATURE You must wait until you are in the presence of a certifying officer to sign this form. Under penalties of perjury, I certify that: 1. The number shown on this form is my correct Taxpayer Identification Number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. Sign Here: (Signature) (Print Name) (Number and Street, Rural Route, or P.O. Box) (E-mail Address) Home Address (City) (State) (ZIP Code) (Daytime Telephone Number) Sign Here: (Signature) (Print Name) (Number and Street, Rural Route, or P.O. Box) (E-mail Address) Home Address (City) (State) (ZIP Code) (Daytime Telephone Number) Instructions to Certifying Officer: 1. Name of person who appeared and date of appearance MUST be completed. 2. Medallion stamps require an original signature. 3. Person(s) must sign in your presence. 4. Complete "RESERVED FOR IDENTIFICATION NOTATIONS" on next page and read the instructions that follow it. I CERTIFY that , whose identity is known or was (Name of Person Who Appeared) proven to me, personally appeared before me this , day of (Month/Year) at , and signed this form. (City/State) (Signature and Title of Certifying Officer) (OFFICIAL STAMP OR SEAL) (Name of Financial Institution) (Address) (City / State / ZIP Code) FS Form 1522 Department of the Treasury | Bureau of the Fiscal Service (Telephone) 2 I CERTIFY that , whose identity is known or was (Name of Person Who Appeared) proven to me, personally appeared before me this , day of (Month/Year) at , and signed this form. (City/State) (Signature and Title of Certifying Officer) (Name of Financial Institution) (OFFICIAL STAMP OR SEAL) (Address) (City / State / ZIP Code) (Telephone) RESERVED FOR IDENTIFICATION NOTATIONS Customer Account Number and Date Established: Document(s) - Description: Identified by (Signature and Address): INSTRUCTIONS TO CERTIFYING OFFICER Each person appearing before you must establish identification by positive and reliable evidence before this form is signed, unless he or she is personally known to you. Place an adequate notation above or on a separate record, showing exactly how identification was established. A notation is adequate if it is sufficiently detailed to permit, at a later date, a determination of the exact identification actually used. You and the organization will be held fully responsible for the adequacy of the identification. The signatures to the request must be executed in your presence. Fully complete and sign the certification form provided for your use for each signature you witness. If you are an employee (rather than an officer) authorized to certify signatures, insert the words “Authorized Signature” in the space provided for the title. Insert the place and date, as required on the form, and impress the seal of your organization. INSTRUCTIONS USE OF FORM – Use this form to request payment of United States Savings Bonds, Savings Notes, Retirement Plan Bonds, and Individual Retirement Bonds. WHO MAY COMPLETE – This form may be completed by the owner, coowner, surviving beneficiary, or legal representative of the estate of a deceased or incompetent owner, persons entitled to the estate of a deceased registrant, or such other persons who may be entitled to payment under the regulations governing United States Savings Bonds. A minor may sign this form if, in the opinion of the certifying officer, he or she is of sufficient competency to understand the nature of the transaction. (See "CERTIFICATION" below.) An incompetent person may not sign this form. COMPLETION OF FORM – Print clearly in ink or type all information requested. ITEM 1. DESCRIPTION OF BONDS – Provide the name(s) of the person(s) shown in the inscription of the bonds for which payment is requested. Describe the bonds by issue date and serial number. If you need more space, attach either FS Form 3500 (see www.treasurydirect.gov), a plain sheet of paper, or a photocopy of this section. ITEM 2. REQUEST FOR PAYMENT The payee's Taxpayer Identification Number must be provided. Furnish the Social Security Number if the payee is an individual. If an estate, trust, or other entity is involved and IRS has assigned an Employer Identification Number, provide that number. ITEM 3. DELIVERY INSTRUCTIONS Furnish the name(s) on the account, the account number, the type of account, and the financial institution's name, the routing/transit number which identifies the institution, and the institution's phone number. You may need to contact the financial institution to obtain the routing number. Please verify account information for accuracy and legibility to avoid a delay in deposit. FS Form 1522 Department of the Treasury | Bureau of the Fiscal Service 3 ITEM 4. SIGNATURE The person(s) requesting payment of the bonds must sign the form in ink, print his or her name, and provide his or her address, daytime telephone number, and if applicable, e-mail address. If the name of a person requesting payment has been changed by marriage or in any other legal manner from the name in the inscription of the bonds, the signature to the request for payment must show both names and the manner in which the change was made; for example, "Miss Mary T. Jones now by marriage Mrs. Mary T. Smith.” (See "CERTIFICATION" below.) CERTIFICATION – The person(s) requesting payment of the bonds must appear before and establish identification to the satisfaction of an officer authorized to certify requests for payment of United States Savings Bonds and sign the request in the presence of the officer. If a minor signs the forms, the officer must be satisfied that the minor is of sufficient competency to understand the nature of the transaction. Authorized certifying officers are available at financial institutions, including credit unions, in the United States. Certification by a notary isn’t acceptable. Examples of acceptable seals and stamps: • The financial institution’s official seal or stamp, including: Signature Guaranteed seal or stamp; Endorsement Guaranteed seal or stamp; Corporate seal or stamp (a corporate resolution isn’t required); or Issuing or paying agent seal or stamp (including name, location, and four-digit identification number or nine-digit routing number). • The seal or stamp of Treasury-recognized Signature Guarantee Programs or other Treasury-approved Medallion Programs. WHERE TO SEND – Unless otherwise instructed, send this form and the bonds, as well as any other appropriate forms and evidence, to the address below. Legal evidence or documentation you submit cannot be returned. Treasury Retail Securities Site PO Box 214 Minneapolis, MN 55480-0214 (Phone: 844-284-2676--toll free) NOTICE UNDER 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 public 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 Fiscal Service and its agents to issue securities, process transactions, make payments, identify owners and their accounts, and provide reports to the Internal Revenue Service. Furnishing the information is voluntary; however, without the information the Fiscal Service 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 to 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 15 minutes to complete this form. However, you are not required to provide information requested 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 Fiscal Service, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND a completed form to this address; send to the address in "WHERE TO SEND" in the Instructions. FS Form 1522 Department of the Treasury | Bureau of the Fiscal Service 4
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File Type : PDF File Type Extension : pdf MIME Type : application/pdf PDF Version : 1.6 Linearized : Yes Author : Stephanie Snyder Comments : Revised 12-16-02 to remove dotted/dashed lines in Description of bond areas on pages 1 and 3.....Revised 8-10-04 to change the five FRB's to the two Treasury Retail Processing Sites. "FRB" above Customer Name and in box for Fiscal Agent Code changed to "official". Company : OIS, IAC, PSG Create Date : 2017:03:07 14:25:14-05:00 Manager : Sonya Ray Modify Date : 2017:11:21 10:54:05-05:00 Source Modified : D:20170307153716 Subject : Request for Payment Has XFA : No Language : EN-US Tagged PDF : Yes XMP Toolkit : Adobe XMP Core 5.4-c006 80.159825, 2016/09/16-03:31:08 Metadata Date : 2017:11:21 10:54:05-05:00 Creator Tool : Acrobat PDFMaker 11 for Word Document ID : uuid:a24e04b4-45cf-404a-b8a0-b785ff0e44a2 Instance ID : uuid:3327bc52-bbec-4324-a8c7-07d543b5dcfc Format : application/pdf Title : PD F 1522 Description : Request for Payment Creator : Stephanie Snyder Producer : Adobe PDF Library 11.0 State : 1 Version : 1.1 Headline : Request for Payment Page Layout : OneColumn Page Count : 4EXIF Metadata provided by EXIF.tools