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For official use only: Customer Name
PD F 5410 E Department of the Treasury Bureau of the Public Debt (Revised April 2008)
Customer No.
APPLICATION FOR REFUND OF PURCHASE PRICE OF UNITED STATES SAVINGS BONDS FOR ORGANIZATIONS
OMB No. 1535-0136
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. The undersigned presents and surrenders for refund the following United States Savings Bonds:
ISSUE DATE FACE AMOUNT BOND NUMBER INSCRIPTION (Provide complete Social Security Number [for example, 123-45-6789], names, including middle names or initials, and addresses on the bonds)
(If you need more space to describe the bonds, use a continuation sheet and attach it to the form.)
2. Refund of the purchase price is requested because:
a. b. c.
The employee has been terminated and is not entitled to the bonds. The employees funds were not used, in whole or in part, to purchase the bonds. The bonds were issued in error and the registrant(s) is/are not entitled. Other
THE CONDITION OF THIS OBLIGATION IS SUCH that if the above-named obligor, its successors or assigns, or any of them, shall well and truly indemnify and save harmless the United States of America from any other claim on account of said security(ies) and interest thereon and from any and all losses which the United States of America may sustain in consequence of any such other claim and shall repay to the United States of America all sums of money which the United States of America may pay on account of said security(ies) and interest thereon with interest, administrative costs, and penalties, then this obligation will be void; otherwise it will remain in full force and effect.
3. Mail check to:
Name
(Organization's Name)
Business Address
(Number and Street or Rural Route) (City) (State) (ZIP Code)
Internet Address
(SEE INSTRUCTIONS ON PAGE 2)
You must wait until you are in the presence of a certifying officer to sign this form. 4. Sign Here:
(Signature of Officer Authorized to Request Refund of Purchase Price)
(Officers Printed Name)
(Officer's Title)
(Telephone No.)
(FAX No.)
(Organization's Name)
(Employer Identification Number)
Certifying Officer The individual must sign in your presence. Complete the certification and affix your stamp or seal.
5. I CERTIFY that
proven to me, personally appeared before me this at
(City) (State)
, whose identity is known or was day of
(Month)
,
(Year)
, and signed this form.
(OFFICIAL STAMP OR SEAL)
(Signature and title of certifying officer) (Street address) (City) (State) (ZIP Code)
IDENTIFICATION NOTATIONS
Customer Account Number and Date Established: Identified by (Signature and Address): Documents - Description:
INSTRUCTIONS
This form is to be used for requesting refund of the purchase price for any of the circumstances shown on Page 1.
Item 1. Item 2. Item 3. Item 4. Item 5.
Describe the savings bonds submitted for refund. Provide the reason the savings bonds are being submitted for refund. If none of the circumstances apply, complete Item 2 (c) and outline the reason for the request. Provide mailing instructions. A person authorized to request refund on behalf of the organization must sign this form, show his/her official title and daytime telephone number. The organization's employer identification number must also be furnished. (See Certification to Form.) The person requesting refund of the bonds listed must appear before and establish identification to the satisfaction of an authorized certifying officer and, in the presence of the officer, sign this request. (See Certification to Form.)
Send the application, the bonds, and any relevant correspondence to the Department of the Treasury, Bureau of the Public Debt, PO Box 7012, Parkersburg, WV 26106-7012.
CERTIFICATION TO FORM
Sign the completed form in the presence of an authorized certifying officer. The certifying officer must complete the certification form and place an adequate notation on this form, or on a separate record, showing exactly how identification was established. The certifying officer must affix the seal or stamp which is used when certifying requests for payment. Authorized certifying officers are available at banking institutions, including credit unions, in the United States, and as provided in Department of the Treasury Circulars Nos. 530 and Public Debt Series Nos. 3-80 and 2-98.
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
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 Public Debt 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 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 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 06 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 Public Debt, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form to the above address; send to correct address shown in the instructions.
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PD F 5410
