Declaration of reclassification Where you stand with the law system

Certificate of identity - DOJ
QUIET TITLE - PULLS OUT OF THE

PUBLIC
AM NOT A BUSINESS

YOU TAKING MY ID IS ILLEGIBLE

Original document Restoration of Former Status
From Being a Public "United States" citizen;
a Federally-owned "U.S. citizen" as of March 9, 1933; and
a Taxpayer/Bondman put to Tribute as of September 8, 1936,
To Becoming Once Again
Under Section I of the 14th Amendment: Constitution of the United States of America
Private Citizen of the United States
3 Linnell Circle
County of YourCounty
Brunswick, YourState
Zip Code Excepted [04011-7533]
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Phone" 207-798-46^5
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Accordingly, 1, First IVlIddle Last, affiant formally known as First Middle Last in some cases, in esse and suf juris, good reason and good conscience, hereby make oath, depose and declare that the following facts are true, correct and complete to the best of rny knowledge and belief.
le Last, do solemnly declare and affirm the following historical facts and distinctions with regard to the status of de jure Private American National citizenship (said original federal citizenship, secured by Article IV, Section 2 of the Constitution of the United States, having been broadened into national citizenship by Section 1 of the 14th Amendment to the Constitution of the United States of America) and on the other hand, a State-created, statutory, de facto Public ^U.S. Citizenship*^ as a basis ©nabling a correction of mistak© by this Declaration. This de facto Public U.S, citizenship, being in substance likened to a privileged Roman citizenship, would enable the constitutionally de jure civilian government of the United States (having been constitutionally altered from being a de jure "Federal" government to a de jure "National" government by the 14th Amendment, 1868} to be replaced with a Congressionally-created, statutory, de facto Emergency War Powers military government of the United States on March 9, 1933, This current de facto government in many ways has in fact replaced the constitutional, de jure jurisdiction of the United States, the "United States" being the collective name of the states which are united by and under the constitution, " (Hooven & Allison Co. v. Evatt, 324 U.S. 652, 672), replacing it with a de facto jurisdiction of the United States", {Hooven & Allison Co, v. Evatt, supra, 671),
American National Citizen^ th@ posterity of th@ People that created these United States,
Further, that unilateral contract was the application for birth certificate/ public filing of a "Certificate of Live Birth". The American application for birth certificate "Certificate of Live Birth" -by operation of law—would be the contract to alter de jure Private American National Citizenship to de facto Public "U.S. Citizenship". With this presumption of fact of an existing contract held by every individual Public "U,SB Citizen" (holding its Private
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American National Citizen of the United States of America as Property and Surety), every court legally sits In a martial, concurrent jurisdiction (in which the forms of Law and Equity have been merged) enforcing the statutes of
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an Emergency War Powers Congress. This de facto status enables and obligates all federal and state courts to sit [n this state of emergency, subverting the Common Law jurisdiction of the United States (as per Section I of the 13th Amendment, and Section ! of the 14th Amendment) by rendering ineffective, the constitutional status of de jure private American National Citizens of the United States of America (Section 1 of the 14th Amendment).
As of March 6, 1933, all Public "U.S. citizens"—with their Surety/Property, Private American National Citizens— were seized as booty of war by President Franklin Roosevelt's martial. Emergency War Powers Proclamation 2039 which practically overthrew the Sovereignty of the People of the United States of America, reducing them to being
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mere property of a de facto military government sitting in Washington, D.C., to be treated as "rebels and
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belligerents" living in the fifty states deemed by the Conqueror/Commander-in-chief to be merely '"'occupied territories", the seized state governors ruling their de facto military governments in subordination to Washington DC,
Therefore, finding this situation of statutory-altered, Private American National Citizenship status intolerable, unconscionable, and at variance and in conflict with the originally established courts of Common Law as well as the courts or exclusive/inherent Equity/Chancery governed solely by the Maxims of Equity, I, First IVliddla of Last, do make oath, solemnly declare and affirm:
1. WHEREAS, the FRANCHISE, CORPORATE SOLE, Cesti Que Trust, via the "application for birth certificate and/or the BIRTH CERTIFICATE" (hereinafter BIRTH CERTIFICATE) being in fact a unilateral contact under seal, was created and offered legally through deceit, in effect, alters, within the current, government, the status of "We the People", which includes every individual Private American National Citizen; first of our sovereignty as a People, then of our constitutionally-created status, and ultimately our lives, fortunes and our sacred honor;
2. WHEREAS, the true purpose of the BIRTH CERTIFICATE, a unilateral contract under seal, is to be a covert commercial agreement and unconscionable by "We the People", adhesion contract/quasi-contract between the state of the baby's natural birth and the mother of the baby, the baby then deemed property of the Federal, de facto military government of the United States (the BIRTH CERTIFICATES being recorded by the Department of Commerce then to serve as collateral securities for the unquestionable public debt as per Section 4 of the 14th Amendment);
3. WHEREAS, the true nature of the DATE OF FILING on the BIRTH CERTIFICATE, a unilateral contract under seal, is to commence the legal birth of the quasi-corporate, artificial person/Public "U.S. citizen" created by all necessary legal elements of a unilateral contract (it being in writing, signed, sealed and delivered for registration and filed with a public office of the baby's state of live birth);
4. WHEREAS, the true nature of the DATE OF BIRTH of the baby named on the BIRTH CERTIFICATE is to commit the natural person/Private American Natural Citizen as Surety, for, and personal property, of the state-created, artificial person/Public "U.S. citizen", both entities being legally wedded into one legal entity, the hybrid, federally-owned, Public "U.S. citizen'',
5. WHEREAS, the BIRTH CERTIFICATE is a BUSINESS INSTRUMENT recorded with the County Recorder, a subsidiary of the Secretary of State (of the several states treated as "conquered territories"), also sent to the Bureau of Census, a division of the Department of Commerce in Washington, D.C.f placing the NAME of the Public "U.S. citizen" into interstate and foreign world commerce as a statutory, legal, "person'' (as corporations, partnerships, trusts, corporate soles, etc.), distinct and separate from the "natural born citizen", i.e. the Private American National Citizen;
6. WHEREAS, the Secretary of State (of the several states) charters corporations and issues franchises, therefore, any natural born citizen/Private American National Citizen with a BIRTH CERTIFICATE is liable to the Franchise Board of the State's Department of Revenue for income/excise/privilege taxes, as well as being liable to the Internal Revenue Service collecting the internal revenue for the "Federal Corporation" of the United States (28 USC 3002 (15)(A) via excise/incorne/privilege taxes in payment of the interest on the national debt (proven by President Ronald Reagan's Grace commission) which interest is owed to the Roman papacy's Federal Reserve Bank;
7. WHEREAS, this BIRTH CERTIFICATE, functioning as a BUSINESS INSTRUMENT, has deceived the Private American National Citizen, First IVliddi© of Last, allegedly named on said certificate, into an unknown and covert implied contract by operation of law, and had placed Affiant and fellow Private American National Citizens under an alien, foreign, and yet "temporary", de facto military jurisdiction of the United States created at first by the 'Emergency Banking Relief Act", in its initial paragraphs containing a congressionally-amended WWI statute known as "Trading with the Enemy Act" and codified as 12 USC 95(a), and secondly by then President Franklin D. Roosevelt's Emergency War Powers Proclamation 2040 decreed on March 9,, 1933;
8. WHEREAS, the above de facto jurisdiction of the United States includes the jurisdiction of the constitutionally-created, federal and state civilian courts (IN FORM) sitting in a martial Roman Equity/At Law (IN SUBSTANCE), they are no longer proceeding against the accused Private American National Citizen with the Mode of a Common Law civilian due process, but rather with the Mode of a Roman Civil Law martial due process that, if unchallenged by producing state-filed public records and other prirna fascia evidence, will confer a martial jurisdiction over the accused, being then forced to plead in a court imposing martial due process and procedure derived from a congressionally-amended World War 1 statute as of March 9, 1933, the judges, federa! and state, acting on behalf of the de facto military dictator/Commander-in-chief sitting in Washington D.C.;
9. WHEREAS, upon the public filing of the BIRTH CERTIFICATE with its attached Private American Citizen serving as Surety and personal property, another "source" was created that would generate "income" which could then be income/excise/privileged taxed; the natural person/baby/Private American National Citizen now wedded to his new artificial person / "U.S. Citizen" as its property and subordinate Surety, the new "source" (deemed a "rebel" and "belligerent" residing according to state statute in a state deemed an "occupied territory") being in commerce and subject to the absolute legislative powers of the "temporary" Emergency War Powers Congress (1933-present) to regulate without limited interstate and foreign commerce pursuant to Article 1, Section 8, Clause 3, of the "United States Constitution" during this time of a "temporary" declared state of National Emergency now 2016 in its eighty-third year;
10. WHEREAS, Affiant, a Private American National Citizen, has presently ceased to be Surety for the personal property of the Public "U.S. citizen" FIRST MIDDLE LAST" by means of a duly filed "Release With Coosiderati Nunc Pro Tune Ab Initio", and "Rescission of Signatures of Syr©ty$hip~~~Nunc Pro Tune Ab Initio", thereby
Page 2 of 5

returning to the former status of being a Private American National Citizen held for less than twenty (20) days after ianfs natural birth:
EftEAS, Affiant in esse? has irrevocably separated himself from the state-created FRANCHISE, CORPORATE SOLE, "United Sates Citizen", created by means of a publicly filed BIRTH CERTIFICATE, hereby revokes all powers, including but not limited to, Powers of Attorney and/or Agency that Affiant may have granted to any third party, public and/or private. Therefore, Affiant does not consent and is not a party to FDR's contract with all "U.S. citizens" by means of Proclamation 2040 confirmed and approved by Congress in its passage of the ^Emergency
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Banking Relief Act" and then thereby amending the trading With the Enemy Atf*. Therefore, Affiant is not in commerce (as are corporations), never to enjoy any commercial privilege of limited liability as a matter of "United States citizenship" status (as do corporations being Public US. citizens), having discharged all de facto Emergency War Power Military Governments, federal and state, from any duty or obligation arisen from Affiant being the Property/Surety for and/or wedded to the state-created hybrid, the federally owned Public "U.S. citizen" in service of Washington D.C., for commerce and war;
IEREAS, I, First IVliddb of Last, have returned to my former status of being an American Freeman and an American National in Equity, i.e. de jure Private National Citizen of the United States under Section 1 of the 14th Amendment and therefore stand "in personam", "in esse", and "sui juris", possessing all God-given unalienable rights including those protected by the first eight amendments of the Bill of Rights, all Constitutional rights (federal and state) and all common Law rights of a de jure Private Citizen of the United States/American National, no longer under the legal disability of being the Property/Surety for and/or wedded to a de facto, state-created, Public ""LLS. citizen" owned by the Federal de facto Military Government of the United States;
13. WHEREAS, I, First Middle of Last, am no longer the Property/Surety for and/or wedded to a de facto Public U,S, citizen" (which is 'yalien juris"), therefore, no longer under the de facto jurisdiction a I power of statutorily-created, de facto Emergency War Powers Governments {federal and state) as those absolute legislative, absolute executive, and absolute judicial powers are exercised towards a de facto Public "U.S. citizen" deemed a "rebel and belligerent" statutorily "residing" in a state deemed "occupied territory", and therefore no longer under the paternal guardianship of de facto Emergency War Powers Governments (federal and state) as those absolute, paternal powers are exercised towards its "infants, children and wards", and the de facto Public U.S. citizens";
14. And so First Mddle of Last, aka First IVIIddle Last, hereby present my renunciation, as to any implied allegiance to the de facto "United Sates",
THEREFORE, based upon the foregoing, \f First Middl© of Last, in esse and sui juris, do make oath, solemnly declare and affirm the following positive averments:
1.    lam one of the Posterity of ^We th© People^ by whom and for whom the Constitution was originally ordained and established according to its Preamble, holding de jure Private American National Citizenship conferred upon my natural birth by section I of the 14th Amendment to the Constitution for the United States.
2.    My Proper name at Common Law is ^Flrst fVHddie", my surname/family name is ^Lasff, I am also known by the name First Middle Last
Proper name "First Middle of Lasf* is spelled in both upper and lower case letters, without capitonyms 'without using all capital-lettered name), in accordance with proper rules of English grammar.
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was naturally born on September the Eighth (8th), the year of our Lord Nineteen Hundred and thirty-six 1936} and was called First Middle Last for many years. My natural and legal parents were Arnold Middle Li
Emergency war Powers Ge¥ernnt©nt; to be unconscionably and mistakenly on public record,
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I was naturally born in the city of Portland, on the land of the County of YourCounty, within the geographical jurisdiction of the YourState State, one of the several States of the Union,
In the day of my natural birth i became a de jure Private American National Citizen of the geographical United States of America (composing the fifty states) pursuant to Section I of the 14th Amendment to the Constitution of the United States of America.
7.    In the day of my natural birth I became a de jure PP
RESIDE NT of the geographical YourState State pursuant to Section I of the 14th Amendment to the Constitution of the United States of America,
8.    On the day my "'Certificate of Live Birth" was filed with the "State of YourState", by operation of law i became the Pro party/Surety and/or and wedded to '"'First Middle Last", a state-created, YourState "corporate sole" and statutory Pyblic WU»S. citizen^ of the de facto "Emergency war Powers Military Government of the "United States", it governing the states as "conquered territories" and its state-created "U.S. citizens" as a conquered people,
9.    Said Property has been returned to the natural owner, said Suretyship has been terminated, the marriage has ended and my former status of Piwate American National Citizen of the United States of America has been restored, pursuant to the maxims of the Law of Contract, The American Common Law, Equity Maxims, Equity Jurisprudence and the Uniform Commercial Code, by means of a duly filed and publicly recorded ^Release Without Consideration—fMunc Pro Tune Ab Inflict*
10.  if a de jure Pmat© American National Citizenship of the Republic is "paramount and dominant", rnyde jure Pmate Citizenship of the Republic of YourState is "subordinate and derivative" of said Private National Citizenship of the United States. Selective Draft Law Cases; 245 U.S. 366, 389 (1918). Private Citizens of the United States were called "American Freemen** by pre~14th Amendment presidents George Washington, Andrew Jackson, Zachary Taylor and Abraham Lincoln, as well as by post 14th Amendment Supreme Court
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12,
13.
14.
Justice John Marshal! Harlan evidenced by his dissent [In U.S. Maxwell v Dow, 176 U.S. 581, 607, 617 (1900 and Downes v. Bidwell, 132 U.S. 2444, 381 (1901)].
I, now Specially arid Pri¥at©Iy Reside without the military jurisdiction of the "United States" as defined by the "Trading With the Enemy Act", and therefore Privately Rasid© within a non-military occupied private estate within the territorial jurisdiction of the geographical Republic of YourState, which I sometimes refer to as The YourState Republic Free State. Therefore I am a Special and Pri¥at@ Resident holding Private Citizenship of the Republic of YourState pursuant to Section 1 of the 14th Amendment
My flags are the civilian flag of the Republic of the United States of America (4 USC 1} and the civilian flag of the Republic of YourState. Neither civilian flag, representing its nation under a republican form of government, displays gold fringe and/or gold cords with gold tassels' as do military colors displayed by the Commander-in-chief of the de facto Military Government of both the United States of America and the Republic of YourState.
My law is the Twenty Maxims of English/American Equity, My seal is private to my family.
Being a non-statutory, constitutionally-protected Private American National Citizen of the Republic of the United States of America and a non-statutory, constitutionally-protected Private Citizen/Special and Private Resident of the Republic of YourState and therefore no longer the Property/Surety for and/or wedded to the YourState "corporate sole" / "Public U.S. citizen" "FIRST IV110DLE LAST I am not in commerce as a matter of persona! status, as are statutory, state-created, Surety-backed Public "U.S. citizens" of the United States, and therefore the sentient, living person "First Middle Last", without a Surety and Persona! Property, is a "Non-Taxpayer" described in Economy Plumbing & Heating vs. United States, 470 F. 2d, 585 at 589 (1972).
i have rescinded every Signature of Suretyship™™ None PraTync Ab Initio—ever executed on behalf of the
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corporate sole / "U.S. citizen" "FIRST IVffDBLE LAST" (including and derivative of the NAME thereof) be it public and/or private, by means of a duly filed ^Rescission of Sigoatyres of Suretyship—Nunc Pro Tone Ab

. The legal Title ho!der(s) and the Equitable Title holder of all legal property of the Private Business Trust "FIRST IV1IBDLE LAST" are private [n nature evidenced by a "Notice of Private Trust Arrangement" filed in the public record,
18.  lam the agent for the Private Business Trust "FIRST MIDDLE LAST" in the acquisition of its legal property by nature evidenced by a "Notice of Proate Trust Agreement** filed in the public record,
19. The Prl¥ate Business Tryst "FIRST MIDDLE LAST" is In U.S. domestic and world commerce, all products being equitable property by nature of a special and private Sole Beneficiary holding the status of a Private Citizen of the United States, secured by Section 1 of the 14th Amendment to the Constitution of the United States of America. Therefore the Private Business Trust "FIRST IVI1DDLE LAST", "has no income", and therefore the trust [s a Non-taxpayer legal entity.
Further, I, First Middle of Last in esse and sui juris, makes oath, do solemnly declare and affirm the following negative averments:
1,    i am not a/fen juris, holding the status of being the Property/Surety for and/or wedded to an artificial, de facto, hybrid Public "U.S. citizen created by state statute in the state of my natural birth for the benefit of the de facto Emergency War Powers Military Government created on March 9, 1933; hence I am neither an infant or a child nor a rebel or a belligerent under the power of a paternal and martial Emergency War Powers Military Government, federal or state.
7      Mv Prnnpr name k not "FIRST MIDDIF 1 AST" "FIRST E  LAST' Pir^t E  Last" or anv other form or derivative
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thereof; of this nom de guerre/nam® of war carried by all "U.S, citizens", which is principal in distinguishing the difference between all of the uppercase names and mixed case names, which has been affirmed by a federal court of record,
3.    My Proper name is not spelled in solely upper case letters or with any abbreviations, which is principal in distinguishing the difference between the all-uppercase name and the mixed case name which has been affirmed by a federal court of record.
4.    I am not "FIRST IV1IODLE LAST", "FIRST E. LAST", or "First E. Lasf*, or any derivative thereof; which is principal in distinguishing the difference between the all-uppercase names and the mixed case names that has been affirmed by a federal court of record.
5.    i am neither the Property/Surety for, nor wedded to the artificial entity "FIRST IVilPDLE LAST, "FIRST E, LAST", "First E. Last" or any other derivative of this nom de guerre/name or war carried by all "US. citizens", said NAfVlE being the legal property by characteristic of the de facto Military Government of the United States of America.
8,    lam neither a statutory, state-created Public "United States citizen", {artificial person) of the sovereign, de facto Military Government of the United States nor am ! Surety for and/or personal property of and/or wedded to a statutory, state-created Public "United States citizen" (artificial person} of the sovereign, de facto Military Government of the United States as a matter of Status and/or a matter of public and/or pri¥at© contract. Therefore, I am not a state-created, federally owned, statutory Public,, "United States citizen" (artificial person/"U.S. citizen") of the sovereign, de facto Military Government of the United States for fncome/excise/prfvilege tax purposes,
7,    My flag&j national and state, are not military colors bordered with gold fringe and/or draped with gold cords with gold tassels.
S*    lam not a rebel^ belligerent or enemy publicly residing within a conquered territory of the "United States" the territory over which the sovereignty of the United States exists", Hoove n, supra p 671), its sovereign, de
| Page 4 of 5
1
facto, Military Government having been created by FDR's presidential proclamation 2040 appr®¥®d and
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confirmed by Congress, "Emergency Banking Relief Act" (12 USC 95b), which act also was amended (via 12 USC 95a) the "Trading with the Enemy Act" (50 USC App, 5(b), on March 9, 1933,
! do not publicly reside according to state statute within a conquered territory or within a federal military district of the geographical Republic of the United States of America (composed of the fifty states). My special, private and confidential location, of living in Equity, on the land of the County of YourCounty may be mailed service at;
First Middle of Last, American National Private Citizen of the United States of America Private Citizen of the Republic of YourState Nation YourState, General delivery Brunswick, Zip accepted near (04011-7355)
! do not pybiiclf r©sid© according to statute within any of the ten regions of the geographical United States of America designated by Zip codes of the Federal Zone Improvement Project begun In 1963 and take exception to whenever and wherever possible in the use of either a ZIP code or a Postal code, both being synonymous.

Further, i, First Middle of Last In esse and sul juris, make oath, do solemnly declare and affirm the foil owing specific negati¥e averments:
1.    Whereas a mistake made by rny natural parents in unknowingly subjecting me, while yet a baby, to the intentions and jurisdiction of this aforesaid temporary de facto government that they misunderstood, and now hold such mistaken act as unconscionable by their own admission?
2.    Am ! not free, under the rules of English American Equity, to correct a mistake for the regard of my own interest?
3.    Can i not now choose by my free will act to properly correct my status by way of this declaration,, for the intention of having proper and peaceful relations with all men?
4.    Are not ail of the aforesaid averments made in this declaration true regarding who I am, and who i am not being?
5.    Are my own parents both not also in the process of a similar status correction action regarding their own interests?
6.    Is it not my intention to see It that my own wife and children have the same proper status as myself, and does our identity belong on the U.S. "Do not Detain Do not Arrest List"?
Further and Finally:
I, First Middle of Last,am a constitutionally-acknowledged and protected, de jure?Pre~I933 Private Ameri National Citizen of the United States of America, and therefore, I am a constitutionally-acknowledged and protected, de jure, Private Citizen of the Republic of YourState, Specially and Privately residing in English/American Equity on the land of YourCounty County, in YourState.
Th©ref0re, I, First Middle of Last, holding the constitutionally-protected private right to a civilian due process of law on both a federal and state level, as well as being unaffected by the "Emergency Banking Relief Act" having imposed a martial dye process of law (by way of the amended "The Trading With the Enemy Act") on any substantfvely, artificial, "person within the United States" deemed federal "booty of war", am as foreign,, by nature and by characteristic, to the extra-constitutional, alien, de facto, temporary" Emergency War Powers Military 6e¥©rn merit of the United State sand owe no temporary allegiance to said "temporary" Emergency War Powers Government. Therefore, I am foreign, by nature and characteristic, to the extra-constitutional, alien, de facto, "temporary" Emergency War Powers Government of the State of YourState and the extra-constitutional, alien, de facto, "temporary", Emergency war Powers Governments of the other forty-nine (49) states and owe no temporary allegiance to said "temporary" Emergency War Powers Military 6®¥©rnment$ having been "temporarily" created by Congress (12 USC 95a) and by President Franklin D. Roosevelt (Presidential Proclamation 2040)on
This "Declaration of Status of First Middle of Last: American National; Pre-1933 Private American National Citizen" supersedes any previous filing with any public office of said Declaration of Status,
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Further Affiant Sayeth Not.

first Middle Last
First Middle Last, American Freeman

American National Pre-1933 Private Citizen of the United States, Private Resident of the Republic of
YourState, Private Resident of the County of YourCounty, Sole Beneficiary for
"FIRST MIDDLE LAST": legal entity formally known as First Middle Last.
Without Prejudice. All Rights and Liberties Reserved.
Page 5 of 5

POWER OF ATTORNEY IN FACT
&
HOLD HARMLESS/ INDEMNITY IDENTITY'S
KNOW ALL MEN AND WOMEN BY THESE PRESENTS:
JOHN ADAM DOE, herein reference to as PRINCIPAL, in the County of ______________, of sound mind, appoints the living man known as John-Adam: Doe; a peaceful, non-belligerent, and non-combatant party, as his true and lawful ATTORNEY IN FACT.
Any and all powers of ATTORNEY IN FACT - NON-ADVERSE, NON-BELLIGERENT, NON-COMBATANT PARTY does supercede any and all former Power of Attorney powers, and furthermore current Powers cures all previous signatures given by principal, In the principal's name, and for the principal's use and benefit, said ATTORNEY IN FACT has full and complete authorization for the facilitation by the conveyance through any communications in translation for assimilation in account science correction techniques in all facets of interstate, intrastate, domestic, and foreign commerce relations with full protection of Safe Harbour and Sinking Funds Provisions for all accounts, proceeds, products, fixtures, and services such as:
1)   Sell, exchange, buy, invest, and / or reinvest any assets and / or property whether by possession and / or ownership, which may have income production or non-income production assets and property,
2)    Open, maintain, and / or close bank accounts: with express provisions for; demand deposit (checks, custodial) accounts, term deposit (savings) accounts, and certificates of deposit, brokerage accounts, and other similar accounts with depository and repository and financial institutions.
a,     Conductanybusinesswithany depository ins titution, any repository ins titu tion, and all financial institution service providers in particular; all issue agents, all transfer agents, and all payout agents with respect to any of principal's accounts. With express provisions for creation of deposits and withdrawals, acquisition and procurement for all bank statements, passbooks, drafts, money orders, warrants, certificates, stocks, shares, bonds, mortgages, encumbrances, liens, financial obligations, promissory notes, bills of exchange, assigns, hardship claims, abandonment claims, salvage claims, quitclaims, and vouchers; either assignable to, assignable to the order of, payable to, pay to, pay to the order of, or payable to the order of, for the principal by any legal person, body corporate, body politic, body ecclesiastical, and any corporation sole..
b.     Perform any act necessary to deposit, negotiate, sell, transfer, or exchange any legal and / or lawful obligation in the style of a note, security, bond, stock, share, of the Treasury of the United States of America, and all Treasuries of every United Nations Member States and all Foreign Governments and their political subdivisions.
c.    Have access to any safe deposit box whether in possession and/or by ownership with the express provision for the contents.
3)   Take any and all legal//aiv/w/ steps necessary to collect any amount or debt due and/or past due, and/or to settle any claim, whether made against or from affirmation on behalf of principal against any other person or entity.
4)    Exercise all stock rights as proxy, with these express provisions for all rights, privileges, and powers with respect to stocks, bonds, debentures, and /or other investments.
5)    Maintain and/or operate any business, personal property, and ownership interests of, with, for, and by principal.
6)    Purchase and/or maintain insurance, re-insurance, and/or bond rights herein.
7)    Enter into legal and lawful bound contracts on behalf of principal.
8)    Employ professional and business assistance as may be appropriate.
9)   Sell, convey, lease, mortgage, manage, insure, improve, repair, or perform any other act with respect to any of principal's property whether as current ownership, possession holder, and/or as potential acquisition and procurements of ownership and/or possession placement, with the express provision for real estate, real estate rights, privileges, powers, without limit to the right to remove tenants and/or to recover possession and settlement. This express provision without limit is also for the right to sell and/or to encumber any current homestead possession and/or ownership and / or potential possession and/or ownership.
10) Transfer any of principal's assets to the trustee of any style of c'est qui trust and / or foreign situs trust; whether it be deed of trust, express trust, irrevocable trust, revocable
POWER OF ATTORNEY IN FACT | Page 1 of 3

trust, and/or any other legal and/or lawful creat/o/? by principal, whether or not said such trust is in existence at the time of such transfer.
11) Prepare, sign, and file documents with any governmental body or agency, with the express provision without limit as authorization to implement account science of units of exchange and units of account for all depository and repository events:
a.    Prepare, sign and file income and other tax returns with federal, state, local, and
other governmental bodies.
b,    Obtain information and / or documents from any government and / or its agencies; and negotiate, compromise, and/
or settle any matter with such government and /or agency/or any/all lawful tax matters.
c.    Prepare applications, provide information, and perform any other act which is a reasonable request by any government and /or its agencies whom have either a sworn oath, sworn affirmation, sworn affidavit of appointment, and public bond, lawful insurance provider, and lawful re-insurance provider in connection with governmental benefits with the express provision for military benefits, social security benefits, health benefits.
12) Make gifts from assets to members of family and to such other persons and / or charitable organizations with whom principal does establish a pattern to provide gifts.
The Principal hereby appoints John-Adam: Doe, the living man, a peaceful, non-belligerent, and

City here
j Country of
non-combatant party; of

as substitute Authorization Representative and for the sole purpose to
provide gifts of property to said ATTORNEY IN FACT, as the event does deem to be appropriate. (13) Disclaim any interest that might otherwise be a transfer or distribution to principal from any other person, estate, trust, and /or other entity, as may be appropriate.
Said ATTORNEY IN FACT-in-fact shall not be liable for any loss that results from a judgment error that was made in good faith. Wherein, said ATTORNEY IN FACT is given grant for a HOLD HARMLESS and FULL INDEMNITY stance in lawf in good faith performance of duty as active action through the authority of this Power of ATTORNEY IN FACT.
Principal authorizes said ATTORNEY IN FACT to further indemnify and hold harmless any third party who accepts and acts under good faith to uphold this document.
Herein given through gift and by grant to said ATTORNEY IN FACT full power and authority to do all and every act and thing whatsoever requisite and necessary to be done relative to any of the current events and their continuation as fully to all intents and purposes as principal might or could do if personally present.
All that said ATTORNEY IN FACT PEACEFUL, NON-ADVERSE, NON-BELLIGERENT, NON-COMBATANT PART/ shall lawfully do or cause to be done under the authority of this power of ATTORNEY IN FACT is express emergency approval. ALL VALID BY THE PRESCRIPTION OF THE LAW OF NECCESITY AND THE DOCTRINES OF UNCONSCIONABILITY AND LA MORT SAISIT LE VIF IN ACCORDANCE WITH APPLICABLE LAWS, CARDINAL ORDERS, ORDINAL ORDERS, AND COMMERCIAL STANDARD; PROVIDES FOR FULL ABSOLUTION THROUGH REDEMPTION.
JOHN ADAM DOE
DNA
Executed this July 28, 2017
By:
©John-Adam: Doe - Living Man; Jus Soli; Sui Juris Power of Attorney-ln-Fact; Master Account Holder; Principal Secured Party; Holder-ln-Due-Course for Title, Lien, and Bond of the private property held in ©JOHN ADAM DOE TRUST™
POWER OF ATTORNEY IN FACT | Page 2 of 3
NOTICE

 

Using a notary on this document does not constitute any adhesion, grant jurisdiction, nor does it
in any manner alter any legal status of any of the parties hereto. The purpose of a notary is
verification and identification only and not for entrance into any foreign jurisdiction,

Dated: this
day of
_, in the year of 20__ A.D.

County,
republic State

 

day of
,20
BEFORE ME, the undersigned authority, on this

to me known to
and personal appearance

be the person whose description is found here in and who does autograph and acknowledges to
me that he does execute the same freely and voluntarily for the uses and purposes therein
expressed,
WITNESS my hand and official seal the date aforesaid.
notary public
(seal)
POWER OF ATTORNEY IN FACT | Page 3 of 3

CERTIFICATE OF AUTHORITY
Request for private banker's license with regards to SSN estate
First Of the family Last
Date of Nativity YYYY-MM-DD Domicil Non Domestic Private Post
c/o 1234 street, on City, State Republic,
on County of YourCounty Non-domestic without the 14th Amendment
Estate Trust FIRST MIDDLE LAST Reg. Date July 28,2017 Fileft
DECREE ORDERS BY TESTIMONY
These involuntary Pledge/Lease FIRST MIDDLE LAST belonging to the private named woman and or child, were fraudulently and involuntarily pledged into the (military) 'civil service' and are subject to and under the trading with the enemy hence public domain, for continuance of 'avatar public business' on behalf of the United States.
Its indisputable that these ALL CAP names avatars are 'private property leased'from the 'original depository, the living woman or child' with regards to the following statement (the unknowingly (Head Count) civilian in a martial law system 1861-2017).
Your Constitutional office is hereby ordered by decree on behalf of these estate interests, that the US Treasury shall rescinded and withdraw from unsecured public civil service and the public domain (to be ordered, privately sealed), therefore, the administrative agencies of the UNITED STATES shall make the return all of the rights, titles and interest and royalties, custodial, warehoused and kept thru the involuntary lease (excise duty and obligation) agreement.
A full payment for Involuntary usufructories, shall be paid back to the private estate source, hence the lender of the name and assets (upper and lower case name here).
The UNITED STATES TREASURY shall immediately approve and license the principal account holder as exclusive authority... First Middle Last, on behalf of the civilly deceased entities FIRST MIDDLE LAST and shall be acknowledged as acting in the capacities of 'private banker source'(creditor) ESTATE-EIN aka fa national banking association' for use by the Original Depository identified on this Certificate of Authority,
You are hereby ordered to vacate the blocks status, and return the controls of these as-set-accounts and make the 100% financial adjustments as to only authorize party and license of the newly create estate, the 'principal account holder7.
You are ordered by decree to discharge and pay all debt public and private related to these accounts, and return the accounts back into balance of zero daily.
CERTIFICATE OF AUTHORITY  Page 1 of 3

You are to provide ledgering of all financial transactions as to support the Attorney of fact and records by sending a ledger once a month as to the accuracy of the accounts.
The UNITED STATES TREASURY shall administrate the above Estate Trust assets held in special trust on behalf of the fee simple owner, in its original jurisdiction, standing without the fatal flaws of the 14th Amendment.
All other third parties are ordered to stand down and are prohibited from any further uses of these accounts without expressed written consent by the principal account holder First Middle Last hence lawful contract laws.
I First Middle Last have caused this action, decree orders, directives, instructions and claim for and on behalf of the civilly dead avatar FIRST MIDDLE LAST and I am hereby am acting as power of attorney 'estate representative', to have a voice and to represent lawful payments, privately and publicly as to its original intent by congress thru the HJR 192, Public law 7310, Stats at large
10 volume 48 pages *1 -112 to pay all debts publicly and privately under the full faith and credit of this nation.
I hereby certify that I am the exclusive principal heir, the only first in line party of interest, which has a absolute full and complete 100% equitable claim of authority, on all assets therein.
The foreign duty and excise tax is hereby authorized to be paid during these administrative processes (a reversion) as to assist in the release of these accounts back to the original party of interests (a remainder), and thru the reorganization of NESARA of the United States (going gold back US notes), the terminations, dissolution of unsecured (debtor) status and classifications of these accounts merged into the estate as res. These accounts are hereby forbidden for usufructory use of third party intervenors. Providing no lawful contract is equal to commercial robbery without authority to do so.
From this point forward, the Office of FIRST MIDDLE LAST ESTATE ESTATE-EIN is to be acknowledged as to the permanent account holder with 100% decisions on release of asset, that all assets are to be merged and deposited into safekeeping for future use of the estate.
You are directed to open a sealed account on behalf of the estate, naming the POA herein numerated as the exclusive representative and registered agent contact.
FULL AND COMPLETE LEDGER OF ACCOUNTING MUST BE PRESENT BY THE US TREASURY of past transactions, for further adjudication on behalf of the leasers on the private name and estate purposes.
FIRST MIDDLE LAST, 'national banking association'
Activated Federal Reserve Account number xxxxxnnn with Routing numbers as follows:
1) Cashers Checks/Certified Checks BRANCH FRB ROUTING NO
2) E-Checks BRANCH FRB ROUTING NO
3) Fed-Wire BRANCH FRB ROUTING NO
CERTIFICATE OF AUTHORITY  Page 2 of 3

The UNITED STATES shall immediately settle all presentments of debt using the sealed SSN account, therefore make the return of the interest/lease back to the Original Depository and issue the "Charge Card" for use by the Certificate holder to charge the account to facilitate the immediate discharge of debts as it arises and make a full account.
The UNITED STATES shall immediately deliver the delinquent rent, which has been held in abeyance in, in a currency of value.
Registration of Intent
The request for issue of a Certificate of Authority by the above referenced American Original Depository establishes the Original Depository's Intent To Withdraw Her Divine Estate from the Military Industrial Complex, discharge the debt in the settlement of the account and return to original jurisdiction.
It is clear that the above reference American Original Depository's intent is to overcome all of the assumptions of his status and re-establish them self as a living being, American Original Depository's return from being lost in a sea of illusion to redeem their Divine Estate and return to original jurisdiction.
Notice to principle is notice to agent, Notice to agent is notice to Principle. Evidence of the issue of this Certificate of Authority is maintained by First Middle Last for verification at any time.
A COPY OF SS CARD
CERTIFICATE OF AUTHORITY  Page 3 of 3

 

RETURN TO:
john-henry of the House of Doe - Without Prejudice
123 Main St.
YourCity, YourState
Non domestic
outside the UNITED STATES
Not in any federal zone, territory, possession, enclave, etc.,
and not subject to the jurisdiction of the United States, et al.

YourCounty County
State of YourState united states of America original jurisdiction
) ss:

This Declaration is made without prejudice

Re: The legal fiction(s) known as JOHN HENRY DOE, any/all derivatives thereof.
I, john-henry of the House of Doe, the undersigned affiant, a living man upon the land of YourState, and not a corporation or legal fiction, etc., born upon the land in the republic of YourState on the day day of Month Year, declare that I am of majority and competent to state the matters set forth herein with first-hand knowledge of the facts and that they are true, correct, not misleading, and certain, admissible as evidence.
1.    This plain statement of Fact being a matter that must be expressed to be resolved. In Commerce truth is sovereign. Truth is best expressed in law in the form of an affidavit. An uncontreverted affidavit stands as truth in commerce and becomes the judgment, can only be challenged by a rebuttal affidavit item for item signed under penalty of perjury, and can only be satisfied by payment, agreement, resolution, or by a trial by jury according to the common law of YourState.
2.    I am presenting this affidavit for truth in commerce and as a Contract for Waiver of Tort.
3.    The public record being the highest form of evidence, I am creating a public record by Declaration of said Copyright by recording with the YourCounty County Recorder of Deeds, the YourState commonwealth.
4.    The person and name known as JOHN HENRY DOE, and any/all derivatives thereof being a legal fiction(s) without form or substance, and without any resemblance to any natural born living being, is entirely an intentional commercial Fiction created by the alleged de facto government officials and agents of the nul tiel COMMERCIAL CORPORATION(s) doing business as, but not limited to; the UNITED STATES, USA, US, GOVERNMENT OF WASHINGTON DC, DISTRICT OF COLUMBIA (including any agencies/persons claiming jurisdiction over any US territories, possessions, enclaves, etc.), et al, FEDERAL RESERVE SYSTEM, DEPARTMENT OF TREASURY, INTERNAL REVENUE SERVICE (IRS), BUREAU OF ALCOHOL, TOBACCO, AND FIREARMS (BATF), FEDERAL BUREAU OF INVESTIGATION (FBI), DEPARTMENT OF HOMELAND SECURITY, CENTRAL INTELLIGENCE AGENCY (CIA), NATIONAL SECURITY AGENCY (NSA), AMERICAN BANKING ASSOCIATION (ABA), AMERICAN BAR ASSOCIATION (ABA), STATE OF TEXAS, STATE OF FLORIDA, COMMONWEALTH OF PENNSYLVANIA, etc., with subdivisions being CORPORATE MUNICIPAL COUNTIES, BOROUGHS, PARISHES, and CORPORATE MUNICIPAL CITY(IES). The FICTION is created for the purpose of disenfranchising the living man, john-henry of the House of Doe of his life, liberty, property and the pursuit for happiness for the unjust enrichment of said CORPORATE and GOVERNMENTAL FICTIONS.
5.    A copyright, copy-claim and trademark is hereby placed on the name and FICTION known as JOHN HENRY
^hereof.—————————————————————————————————————————

john-henry of the House of Doe Declaration of Copyright for JOHN HENRY DOE©    AL-030368-CN  |   Page 1 of 4

 

Any indentures, debentures, bonds, securities, judgments, warrants or any other kind of commercial paper issued or predicated on the name of the legal FICTION known as JOHN HENRY DOE©, shall become a Security Agreement between the issuing party and the affiant and shall make the issuer liable for damages and penalties as follows:
1.    Any usage shall incur a debt of $1,000.00 US in Silver Dollar Coin convertible at the legal and lawful ratio prescribed by law of 24:1 of Federal Reserve Notes to Silver Dollars per day per usage per signatory;
2.    Failure to correct the unjust usage in a timely manner upon notice will result in the additional penalty of $1,000.00 US in Silver Specie convertible at the legal and lawful ratio prescribed by law of 24:1 of Federal Reserve Notes to Silver Dollars per day; and,
3.    Failure to render the appropriate funds in a timely manner will result in a Lien/Levy against the property of the person violating said copyright, as no controversy will exist.
Anyone placing the copyrighted, copy-claimed and trademarked JOHN HENRY DOE© or any derivations thereof on any document which is in any way associated with Me, the living soul, john-henry of the House of Doe, shall, by such document acting prima facie as evidence of violation, become liable for penalties payable in legal and lawful tender of:
a.    Ten ($10.00) dollars US in Silver Dollar Coin convertible at the legal and lawful ratio prescribed by law of 24:1 of Federal Reserve Notes to Silver Dollars per day until Notice is delivered:
b.    One hundred ($100.00) dollars US in Silver Dollar Coin convertible at the legal and lawful ratio prescribed by law of 24:1 of Federal Reserve Notes to Silver Dollars per day for each day AFTER Notice is received until the offending document is destroyed and a public retraction is made in the local newspaper in a double-wide column of not less than three (3") inches in length, if such notice is published within thirty (30) days of Notice;
c.    One thousand ($1,000.00) dollars US in Silver Dollar Coin convertible at the legal and lawful ratio prescribed by law of 24:1 of Federal Reserve Notes to Silver Dollars per day for each day after Notice if such retraction is not published within thirty (30) days of said Notice; and,
d.    Notice will be based upon the records of the commercial business that affects delivery.
JOHN HENRY DOE© is the perfected proprietary security for the living soul john-henry of the House of Doe, under original common law for one hundred (100) years and is private property for the protection of My estate, life, liberty, and property.
Unauthorized possession or use of JOHN HENRY DOE© and any/all derivatives thereof may be a violation of State Code for Fraudulent Use or Possession of Identifying Information which is punishable by prison and fine.
Any use of JOHN HENRY DOE© and any/all derivative(s) thereof, with or without scienter, at the expense of any right, liberty, property, or any part of My estate, absent full disclosure and lacking written prior consent is strictly forbidden and chargeable to each of the users/issuers in the amount of the sum certain of one million ($1,000,000.00) dollars of legal and Lawful Silver Dollar Coin of the United States, convertible at the legal and lawful ratio of 24:1 to Federal Reserve Note Dollars as prescribed by law and is not limited by any past, present, or future restriction for each instance of said unauthorized use.
Placement of JOHN HENRY DOE© on any document associated in any manner with My estate or Me, john-henry of the House of Doe, without My written prior consent is all of the evidence required for enforcement of this agreement/contract and is evidence that any and all users and issuers are in full agreement and have accepted this agreement/contract without controversy under the conditions and terms so stated and set forth herein.
I, john-henry of the House of Doe, am not an expert in the law, however, I do know right from wrong. If there is any living man that is being unjustly damaged by any statements herein, he/she will inform Me by facts in the form of a signed and sworn Affidavit. Therefore, I hereby and herein reserve the right to amend and make amendment to the attached Instrument as necessary in order that the truth may be ascertained, and proceedings justly determined. If any living soul has information that will controvert and overcome this signed and sworn Declaration in this commercial matter, you must advise Me of the facts in the form of a signed and sworn Commercial Affidavit within ten (10) days from recording hereof, proving with particularity by stating all requisite actual evidentiary fact and all
^
john-henry of the House of Doe Declaration of Copyright for JOHN HENRY DOE©    AL-030368-CN  |   Page 2 of 4

 

substantially and materially false sufficiently to change materially My or the fictions status and factual declaration. Your silence stands as consent to, and tacit approval of, the factual declarations here being established as fact as a matter of law and this affidavit by Declaration will stand as final judgment in this matter; and for the sum certain herein stated and will be in full force and effect against all parties, due, payable and enforceable by law. The criminal penalties for commercial fraud is determined by jury and by law, the monetary value is set forth by Me for violation of My Private Property and for breach of the law, the contract, the Constitutions, in the amount of the sum certain stated herein of two million five hundred fifty thousand ($ 2,550,000.00) dollars specie of Gold coin or lawful coinage of the united States as defined by Article I, Section 10 of the Constitution of We the People for the united States of America and will be due, payable on the eleventh day, and any day there after as use occurs after filing by Me, in the public records of the county of YourCounty, in the YourState Republican commonwealth.
Notice to the agent is notice to the principal. Notice to all agents of the State of YourState and all subdivisions thereof is made by the filing of this document with the YourCounty Notary, YourState.
Further affiant sayeth not!

ALL RIGHTS RESERVED,
FOR COPY-CLAIM OF JOHN HENRY DOE© and any/all derivatives thereof.

By
Debtor, Granto

ACCEPTANCE

no do I us
By

Honourable John-henry of the House of Doe, living soul, sui juris, Agent, a lawful Man and Attorney-in-Fact for JOHN HENRY DOE©, Secured Party, Trustee, Right living seal thumbprint In red ink. Pursuant to: at Lee County Florida, and "The Law of Land Warfare" file #549875, book 3681, pages 3945-3949 and book 3681, pages 3956-3958, 3963-3964, and 3869-3970. Also, applicable rule #74, 75, and 79 to knowingly communicate or correspond "without proper authority ...""., ETAL

This document prepared by John-henry of the House of Doe

john-henry of the House of Doe Declaration of Copyright for JOHN HENRY DOE©    AL-030368-CN  |   Page 3 of 4

 

ACKNOWLEDGMENT/NOTARY

 

Using a notary on this document does not constitute any adhesion, nor does it alter my status in any manner. The purpose for this notary is verification and identification only and not for entrance into any
foreign jurisdiction.

 

JURAT

YourCounty County	)
) ss:
State of Yourstate	)
outside the UNITED STATES original jurisdiction
The above affiant, personally known to Me, or proved to Me on the basis of satisfactory evidence, to be the one whose address (name) and autograph is subscribed to the within instrument. Affiant swears under the pains and penalties of perjury that all statements made herein are true, correct, certain, and not misleading.

Duly subscribed and sworn on this
day of
, 2017.

X
Notary Public

(seal)

john-henry of the House of Doe Declaration of Copyright for JOHN HENRY DOE©    AL-030368-CN  |   Page4of4

 

FORM APPROVED OMB NO. 1103-0016 EXPIRES 05/31/2020

 

Privacy Act Statement In accordance with 28 CFR Section 16.41(d) personal data sufficient to identify the individuals submitting requests by
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mail under tlie Privacy Act of 1974, 5 U.S.C. Section 552a, is required. The purpose of this solicitation is to ensure that the records of individuals who are the subject of U.S. Department of Justice systems of records are not wrongfully disclosed by the Department. Requests will not be processed if this information is not furnished. False information on this fonn may subject the requester to criminal penalties under 18 U.S.C. Section 1001 and/or 5 U.S.C. Section 552a(i)(3).
Public reporting burden for this collection of information is estimated to average 0.50 horn's per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Suggestions for reducing this burden may be submitted to the Office of Information and Regulatory Affairs, Office of Management and Budget, Public Use Reports Project (1103-0016), Washington, DC 20503.

Full Name of Requester

 

9	^
Citizenship Status   ___________________ Social Security Number

Current Address

Date of Birth	Place of Birth
OPTIONAL: Authorization to Release Information to Another Person
This form is also to be completed by a requester who is authorizing information relating to himself or herself to be released to another person. Further, pursuant to 5 U.S.C. Section 552a(fa), I authorize the U.S. Department of Justice to release any and all information relating to me to:

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that I am the person named above, and I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. Section 1001 by a fine of not more than $10,000 or by imprisonment of not more than five years or both, and that requesting or obtaining any record(s) under false pretenses is punishable under the provisions of 5 U.S.C. 552a(i)(3) by a fine of not more than $5,000.

Signature
Date

 

Name of individual who is the subject of the record(s) sought
2	.                                            .                     ~
Individual submitting a request under the Privacy Act of 1974 must be either "a citizen of the United States or an alien lawfully
admitted for permanent residence," pursuant to 5 U.S.C, Section 552a(a)(2). Requests will be processed as Freedom of Information Act requests pursuant to 5 U.S.C, Section 5525 rather than Privacy Act requests, for individuals who are not United States citizens or aliens
3
Providing your social security number is voluntary. You are asked to provide your social security number only to facilitate the identification of records relating to you. Without your social security number, the Department may be unable to locate any or all records pertaining to you.
4     .
Signature of individual who is the subject of the record sought.
FORM DOJ-361

 

 

FS Form 0385 (Revised June 2016)
OMBNo. 1530-0026

BUREAU OF THE
Certificate of Identity

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and
I certify that the names

 

refer to the same person, whose correct name is
The names are different because:
The source of my knowledge is:

Is there now or was there during
(Date or Period of Time)
of these names?       Yes
No     If Yes, please explain:

any other person known to you by either or any

 

Sign Here:
(Daytime Telephone Number)
(Signature)

 

(Mailing Address)
(E-mail Address)

 

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, whose identity(ies) is/are
CERTIFY that
(Name[s] of Person[s] Who Appeared)

day of
(Month/Year)
known or proven to me, personally appeared before me this

and signed this form.
at
City, State

 

(Signature and Title of Certifying Officer)

(Name of Financial Institution)

 

(Address)
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Department of the Treasury Internal Revenue Service
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individuals,

 

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name 01 dus
3      Executor, administrator, trustee, "care of3' name

ling address (room, apt., suite no. and street, or P.O. box)

5a    Street address (if different) (Do not enter a P.O. box,

5b    City, state, and ZIP code (if foreign, see instructions)

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state (SSN of decedent)

Partnership

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10      Reason for applying (check only one box)
Started new business (specify type)
Hired employees (Check the box and see line 13. Compliance with IBS withholding regulations 0

Banking purpose (specify purpose) ^______ Changed type of organization (specify new type) Purchased going business ^ated a trust (specify type]

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less in a annually inste
If no employees expected, skip line 14.

endar year and want to file Form 9 of Forms 941 quarterly, check here, tax liability generally will be $1

or less if you expect to pay $4,QQQ or less in total wages.) If you do not check this box, you must file
First date wages or annuities were paid (month, day, year). Note, If applicant is a withholding agent, enter date income will first be paid to nonresident alien (month, day, year) a    a

16     Check one box that         describes the principal
activity of your business.
warehousing
Wholesale-agent/broker Wholesale-other      |_   Re
Accommodation &food service

 

17      Indicate principal line of merchandise sold, specific construction work done, products produced, or services provided.

18
Has the applicant entity shown on line 1 ever applied for and received an EIN? If "Yes," write previous EIN here

Complete this section only if you want to authorize the named individual to receive the entity's EIN and answer questions about the completion of this form.

signees name
Designee's telephone number (include area code)

 

Address and ZIP code
Designee's fax number (include area code

Applicant's telephone number (include area code)
Under penalties of perjury, I dec are that! have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete. Name and title (type or print clearly) ^

Applicant's fax number (include area code)

Signature

 

, 1
. NO,

 

. 1
Form
(Rev.

Department of the Treasury internal Revenue Service

 

YOUR SSN NAME Estate

 

name
name on line
3      Executor, administrator, trustee, "care of" name
Your Living Name

address

 

5b    City, state, and ZIP code (if foreign, see instructions)

America, State where born

 

T S	^'"S, X*\ h.   S         IT™! St   i                         ^™ I h.   I
7b    SSN, ITIN, or BIN
7a    Name of principal officer, general partner, grantor, owner, or trustor

,
is application for a limited liability company (LLC) (or eign equival

IE	IB
IE	IB
IE	IB
IE	IB
IE	IB
IE	IB

 

0

Trust (TIN of grantor)
Corporation (enter form number to be filed)
nee

rarmerss cooperative

Other (specify)
Indian tribal governments/enterprises
Group Exemption Number (GEN) if any

jbh ^ asset exchange
\^ j	P^            ——————————————————————————————————————————————————————————————————————
specify new type) > _________
Started new business (specify type)

Purchased going business Created a trust (specify type) Created a pension plan (spec!
Hired employees (Check the box and see line 13.)

in

4,000 or less in total wages in a

es."

 

15     First date wages or annuities were paid (month, day, year). Note, If applicant is

withholding agent, enter date income will first
N/A

care & social assistance on
Wholesale-aqent/broker

 

17      Indicate principal line of merchandise sold, specific construction work done, products produced, or services provided.

If "Yes/3 write previous E!N here

 

Complete this section only if you want to authorize the named individual to receive the entity's EIN and answer questions about the completion of this form.

Designee's telephone number (include area code)
ignees name

 

Address and ZIP code
Designee's fax number (include area code)

 

Applicant's telephone number (include area code)
Under penalties o! perjury,   declare that  have examined this application, and to the best ol my know edge and belief, it is true, correct, and compete
Name and title (type or print clearly) ^    YOUP Living Name,       EXGCUtOr/FidUCJary

Applicant's fax number (include area code)

Signature

 

Form
. 16

. 1
Form
(Rev.

Department of the Treasury internal Revenue Service

 

1       Legal name of entity (or Individual) for whom the EIN is being requested
\Zf	*f        \                                                                           /                                                                                                                                                              -w*                  ™

name or dus
name on line
ee,   care or   name

 

4a    Mailing address (room, apt., suite no, and street, or P.O. box)

gn, see ins
5b    City, state, and ZIP code (if foreign, see instructions)

6      County and state where principal business is located

T S	^'"S, X*\ h.   $          IT*1! St   i
7b    SSN, ITIN, or
J         !     I     S   i     1 f

 

this application for a limited liability company (LLC) (or eign equival

IE	IB
if 8a is "Yes,53 was the LLC organized in the United States?

BBIBBiSIBBiSIBB

Spp tnP in <S?C?     8.S  SO    i I  I

Trust (TIN of grantor)
Corporation (enter form number to be filed)

rarmerss cooperative

Group Exemption Number (GEN) if any

Started new business (specify type)
Banking purpose (specify purpose) >_______
Changed type of organization (specify new type)
Purchased going business
Created a trust (specify type) > ________
Created a pension plan (specify type) >•

11      Date business started or acquired (month, day, year).         instructions.

13     Highest number of employees expected in the next 12 months (enter -0- if none), no employees expected, skip line 14,
14    If you expect your employment tax liability to be $1,000 or less in a full calendar year and want to file Form 944 annually instead of Forms 941 quarterly, check here. (Your employment tax liability generally will be $1,GOG or less if you expect to pay $4S000 or less in total iges.) If you do not checN
••«?	/         »?
' r.
agent, enter date income will first be paid to
irst date wages or annuities were paid (month, day, year). Note, If applicant is a withholdin nonresident alien (month, day, year) „    „

Health care & social assistance
16     Check one box that         describes the principal activity of your business.

on
enousmg

 

17      indicate principal line of merchandise sold, specific construction work done, products produced, or services provided.
18      Has the applicant entity shown on line 1 ever applied for and received an EIN?
If "Yes," write previous E!N here >-	\
Complete this section only if you want to authorize the named individual to receive the entity's EIN and answer questions about the completion of this form.

ignees name
Designee's telephone number (include area code)

 

Address and ZIP code
Designee's fax number (include area code)

Applicant's telephone number (include area code)
Under penalties o! perjury,   dec are that I have examined this application, and to the best of my knowledge and belie!, it is true, correct, and complete. Name and title (type or print clearly)

Signature

 

Cat. No. 16055N
(Rev. 1-2010)
 
,-X•.-X•.-X•.-X•.-X•.-X•.-X•.-X•.-X•.-X•.-X•.-X•.-X•.-X•.-X•.-X•.-X•.-X•.-X.-X.-X.-X.-X.-X.-X.-X.-X.-X.-X.-X.-X.-X.-X.-X

V$^VJX*X*X*X*X*X*X*X*X*X*X*X*X*X*X*X*X*X*X*X*X*X*^^

 

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^.«.«.«.«.«.«.«.«.«.«.«.«.«.^^

B No. 1545-2159

ev. December 2
Department of the Treasury internal Revenue Service

 

 

2       Employer identification number
1        Name of person for whom you are acting (as shown on the tax return)
3       Address of financial institution (number, street, and room or suite no.)

4       City, state, and ZIP code
5      Telephone no.

 

Thrift
j?S
Check the applicable box for the type of financial institution:      ZJ   Bank
Check here > LJ if the financial institution is insolvent,
Enter the ending date of the financial institution's tax year (mo., day, yr

s name

 

11       Address of fiduciary (number, street, and room or suite no.)

12       City or town, state, and ZIP code
13    Telephone no.

14       Check the applicable box if the fiduciary is a: Receiver        _    Conservator

Check this box ^LJ    if the financial institution is or was a member of a through 21 are to be completed only if the financial institution is or was a

ng a consolidated return and complete lines 16 to 21 below: Lines 16 of a group filing a consolidated return.

loyer identification number
16       Name of person for whom you are acting (as shown on the tax return'
*	j*                                         •**.?   \                                                                                         «
1S       Address of the common parent (number, street, and room or suite no

19       City, state, and ZIP code

 

Check here > LJ if a copy of this form has been sent to the common parent of the group. Enter the tax year(s) that the financial institution is or was a member of the consolidated group

 

'eceiver
Order of insolvency
ss
iarv relations

 

 

en communications s
notices and other written communications with regard on line 1) will be addressed to the fiduciary. Indicate below fiduciary. Include the type of tax, tax periods or years invo!
This Private Bank   ESTATE has NONE   Non USURY account.

 

!4     Evidence of termination or revocation of fiduciary authority (Check applicable box(es)):

er re
iquci

Copy of certificate of dissolution or termination of a business entity attache Other evidence of termination of fiduciary relationship (describe)
certify that I have the authority to execute this notice concerning fiduciary relationship on behalf of the taxpayer.
^	=/                                                                                                                                                          -ct                                      J?                                                    i                                                                                                   ay

Date
le, it a
s s
ie

 

Cat. No. 12784J
Form
ev. 12-2009

 

 

X'^/HI'X'X'X'X'X'X

 

 

 

FS Form 1455 (revised June 2017)
0MB No. 1530-0035

BUREAU OF THE
Request by Fiduciary for Distribution of United States Treasury Securities

_	iliillillllllillllili
One or more fiduciaries (individual or corporate) must use this form to request distribution of United States Treasury Securities to the person lawfully entitled due to distribution of a trust or an estate or other reasons set out in the instructions.
I/We request distribution of the securities and/or related payments for the following reason:
Distribution of an estate OR trust to person(s) entitled Other reason for distribution:

If a person entitled to paper savin ... payment, they must submit F ... reissue to themselves, they ... reissue to a trust, they must
A person entitled to electronic sec

Part B - Distribution of Securities
I/We request that the securities and/or related payments be distributed as follows: 1. Distribute to:

(Name)

 

(Telephone Number)
(Social Security Number or Employer Identification Number)

(Address)

 

2. Description of securities and/or related payments:

Issue
•Illiilllliilli

 

NOTE: Individual savings bonds (Series EE, E, I, HH, and H) may not be split. Each savings bond must be distributed, in its entirety, to an entitled individual or entity. Marketable securities may be distributed in full or in increments of $100.
If you want to split a marketable security, describe the exact amount of the distribution:

1
FS Form 1455
Department of the Treasury \ Bureau of the Fiscal Service

I/We request that the securities and/or related payments be distributed as follows: 1. Distribute to:

(Name)

 

(Social Security Number)
(Employer Identification Number)
OR

 

(Address and Telephone Number)

 

2. Description of securities:

Issue

•lilliliHllliS

 

NOTE:  Individual savings bonds (Series EE, E, I, HH, and H) may not be split.  Each savings bond must be distributed, in its entirety, to an entitled individual or entity. Marketable securities may be distributed in full or in increments of $100.
If you want to split a marketable security, describe the exact amount of the distribution: ____________________________
I/We request that the securities and/or related payments be distributed as follows: 1. Distribute to:

(Name)

 

(Social Security Number)
(Employer Identification Number)
OR

 

(Address and Telephone Number)

 

2. Description of securities:

 

••iiiiiiiiii

 

NOTE:  Individual savings bonds (Series EE, E, I, HH, and H) may not be split.  Each savings bond must be distributed, in its entirety, to an entitled individual or entity. Marketable securities may be distributed in full or in increments of $100.
If you want to split a marketable security, describe the exact amount of the distribution:

FS Form 1455
Department of the Treasury | Bureau of the Fiscal Service

I/We certify under penalty of perjury that the information provided herein is true and correct to the best of my/our knowledge and belief, and agree to distribution of the securities as indicated in Part B. I/We bind ourselves, our heirs, legatees, successors and assigns, jointly and severally, to hold the United States harmless on account of the transaction requested, and to indemnify unconditionally and promptly repay the United States in the event of any loss which results from this request, including interest, administrative costs, and penalties. I/We consent to the release of any information regarding this transaction, including information contained in this form, to any party having an ownership or entitlement interest in the securities or payments.
Sign Here: ______________________________________________________
(Signature) (Applicant's Title)
(Number and Street, Rural Route, or PO Box)	(City)                      (State)                (ZIP Code)
(Daytime Telephone Number)	(E-Mail Address)

iiiiiliiiiiiii

 

, whose identity is known or
certify that
(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)
(Address)
(City, State, ZIP Code)
(Telephone)
FS Form 1455	Department of the Treasury | Bureau of the Fiscal Service

 

Sign Here:

 

(Signature)

 

(Applicant's Title)

(State)
(City)
(ZIP Code)
(Number and Street, Rural Route, or PO Box)

(Daytime Telephone Number)
(E-Mail Address)

 

^

 

, whose identity is known or
CERTIFY that
(Name of Person Who Appeared)

day of
(Month/Year)
proven to me, personally appeared before me this

at
, and signed this form.

 

(City/State)

 

(Signature and Title of Certifying Officer)

(Name of Financial Institution)

 

(Address)

 

(City, State, ZIP Code)

 

(Telephone)

 

Instructions

 

Use of Form - One or more fiduciaries (individual or corporate) must use this form to establish entitlement and request distribution of United States Treasury Securities and/or related payments to the person lawfully entitled due to termination of a trust, distribution of an estate, attainment of majority, restoration to competency, or other reason.
If you need more space for any item, use a plain sheet of paper or make photocopies of the relevant section, and attach to the form. NOTE:  For reissue to the estate, use FS Form 4000.  For payment to the estate, submit FS Form 1522.
Mark a box to show the reason for the distribution. If you mark "Other," describe the reason, such as attainment of majority or restoration to competency.
Submit a copy of all evidence that establishes your authority to request this transaction. For example, if you are the administrator or executor of an estate, provide a certified copy of your letters of appointment, dated within one year of submission. Submit certified copies of death certificates for all deceased registrants.

FS Form 1455
Department of the Treasury | Bureau of the Fiscal Service

Complete Items 1 through 2.
1.    Enter the name of only one distributee in each Part B, Item 1. (A separate Part B must be completed for each distributee.)  Enter the appropriate Social Security Number or Employer Identification Number.
2.    Describe only the securities and/or checks which the person shown in Item 1 is to receive:
•       TITLE OF SECURITY - Identify each security by series, interest rate, type, CUSIP, call and maturity date, as appropriate. If describing a check, insert the word "check."
•       ISSUE DATE - Provide the issue date of each security or check.
•       FACE AMOUNT - Provide the face amount (par or denomination) of each security or check.
•       IDENTIFYING NUMBER (if applicable) - Provide the serial number of each security, the confirmation number, or the check number.
•       REGISTRATION - Provide the registration of each security, check, or account; also provide the account number, if any. Examples:

 

Paper Marketable Security 9 1/8 % TREASURY BOND OF 2004-2009 MATURES 5/15/09 CUSIP 91281OCG1
Serial # 123
JOHN DOE AND JANE DOE SSN 222-22-2222
ACCT# 4800-123-1234 JOHN DOE SSN 222-22-2222
5/15/79
$5,000
Electronic Marketable Security CUSIP 912795QW4
$1,000
2/5/04

 

Confirmation # 12345
Electronic Series I Savings Bond SERIES!
1/1/02
$100
JOHN DOE
SSN 222-22-2222 JOHN DOE OR JANE DOE
JOHN DOE
Serial #
C-123,456,789-
Paper Series EE Savings Bond SERIES EE
$100
7/99
Check# 502123456
Check CHECK
$351.02
7/26/04

 

If unsure what to provide in each of the areasf furnish all identifying information in the space for REGISTRATION.
n all cases, we need an additional form or forms from the distributee. When paper savings bonds (Series EE, E, I, HH, or H) are distributed, and the entitled person wants:
•      Payment, he or she must submit FS Form 1522
•      Reissue to themselves, he or she must submit FS Form 4000
•      Reissue to a trust, he or she must submit FS Form 1851
When electronic securities held in a Treasury Direct account are distributed, the entitled person must submit FS Form 5446. He or she should complete only the appropriate pages, as indicated on the form.
When distributed to an entitled person or entity, individual savings bonds (Series EE, E, I, HH, and H) may not be split. Each bond must be distributed, in its entirety, to an entitled individual or entity. Marketable securities may be distributed in full or in increments of $100. To split marketable securities, describe the exact amount of the distribution.
Our forms may be downloaded atwww.treasurydirect.gov .
If an entitled person wants payment of paper marketable securities, not held electronically, the fiduciary must complete the assignment on the reverse of the security. The distributee must complete IRS Form W-9.
Any interest that is or becomes due on securities belonging to the estate of a decedent will be paid to the person to whom the securities are distributed, unless otherwise requested.

FS Form 1455
Department of the Treasury | Bureau of the Fiscal Service

Signatures - The form must be signed in ink. Sign the form in your fiduciary capacity. If the request is on behalf of a corporate fiduciary, the name of the corporation must be given, followed by the signature and title of an authorized officer. If there are two or more fiduciaries, all must join in the request unless by express statute, decree of court, or the terms of the instrument under which the fiduciaries are acting, one or more of them may properly execute the request
Certification - Each person whose signature is required must appear before and establish identification to the satisfaction of an authorized certifying officer. The signatures to the form must be signed in the officer's presence. The certifying officer must affix the seal or stamp which is used when certifying requests for payment. Authorized certifying officers are available at most financial institutions, including credit unions. 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.

Sample certification for a financial institution:
SIGNATURE GUARANTEED
ABC National Bank
Hillview Branch

Acceptable certification for a brokerage:
SIGNATURE GUARANTEED
MEDALLION GUARANTEED
Generic Brokerage

Authorized Signature
Authorized Signature
XXXXXXXX
SECURITIES TRANSFER AGENTS MEDALLION PROGRAM
[Bar Code]

Additional Evidence - The Commissioner of the Fiscal Service, as designee of the Secretary of the Treasury, reserves the right in any particular case to require the submission of additional evidence.
Where To Send -Unless otherwise instructed in accompanying correspondence, send this form (without instruction pages) and send the securities, if any, to the appropriate address below. Legal evidence or documentation you submit cannot be returned.
•       Series H or Series HH savings bonds -Treasury Retail Securities Site, PO Box 2186, Minneapolis, MN 55480-2186.
•       Definitive (paper) savings bonds-Treasury Retail Securities Site, PO Box 214, Minneapolis, MN 55480-0214.
•       Book-entry savings bonds and marketable securities held in TreasuryDirect-Treasury Retail Securities Site, PO Box 7015, Minneapolis, MN 55480-7015.
•       Marketable securities held in Legacy Treasury Direct-Treasury Retail Securities Site, PO Box 9150, Minneapolis, MN 55480-9150.
•       Definitive (paper) marketable securities - Bureau of the Fiscal Service, PO Box 426, Parkersburg, WV 26106-0426.
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 30 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 completed form to this address; send to the appropriate address shown in "Where To Send" in the Instructions.

FS Form 1455
Department of the Treasury | Bureau of the Fiscal Service

 

 

FS Form 0385 (Revised June 2016)
OMBNo. 1530-0026

BUREAU OF THE
Certificate of Identity

(iiiiiii;(;(iiiii;ii(iii

 

 

and
I certify that the names

 

refer to the same person, whose correct name is
The names are different because:
The source of my knowledge is:

Is there now or was there during
(Date or Period of Time)
of these names?       Yes
No     If Yes, please explain:

any other person known to you by either or any

 

Sign Here:
(Daytime Telephone Number)
(Signature)

 

(Mailing Address)
(E-mail Address)

 

lllllllllili

 

, whose identity(ies) is/are
CERTIFY that
(Name[s] of Person[s] Who Appeared)

day of
(Month/Year)
known or proven to me, personally appeared before me this

and signed this form.
at
City, State

 

(Signature and Title of Certifying Officer)

(Name of Financial Institution)

 

(Address)
n s$ c ? . o r no —^ TCi	"S p £$	:> s o n ^ r \ $ r^-
v'!   t    ^.5\-.J    -t-.-.---5 V" i   \-.--^ S \-.-< 1,\-.--	\-.-.--W\-.^	,	Vy^^vii   k-.^ 1, U-?    V,-
!	••	v.-.,-1
(City, State, ZIP Code)

 

(Telephone)

 

1
FS Form 0385
Department of the Treasury | Bureau of the Fiscal Service
INSTRUCTIONS
A person who has NO interest in the securities must complete and sign this form, confirming the individual's identity. Unless otherwise instructed in accompanying correspondence, mail this form to the Treasury Retail Securities site that requested it or to the appropriate address below:
•     Series H or Series HH savings bonds -Treasury Retail Securities Site, PO Box 2186, Minneapolis, MN 55480-2186
•     Definitive (paper) savings bonds -Treasury Retail Securities Site, PO Box 214, Minneapolis, MN 55480-0214
•     Book-entry savings bonds and marketable securities held in TreasuryDirect -Treasury Retail Securities Site, PO Box 7015, Minneapolis, MN 55480-7015
•     Marketable securities held in Legacy Treasury Direct -Treasury Retail Securities Site, PO Box 9150, Minneapolis, MN 55480-9150
•     Definitive (paper) marketable securities - Bureau of the Fiscal Service, PO Box 426, Parkersburg, WV 26106-0426
CERTIFICATION
Person who signs form - You must sign the form in the presence of an officer authorized to certify assignments or requests for payment of United States savings and retirement securities. Authorized certifying officers are available at financial institutions, including credit unions, in the United States. For complete lists of such officers, see Department Circulars, Nos. 300 and 530, and Public Debt Series, Nos. 3-80 and 2-98.
Certifying officer - The 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. You must complete and sign the certification form and affix your organization's seal or stamp. If you are an employee (rather than an officer) authorized to certify, insert the words "Authorized Signature" in the space provided for the title.
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 that it will take you about 10 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 completed form to this address; send to the appropriate address in the first paragraph of the Instructions.
FS Form 0385	Department of the Treasury | Bureau of the Fiscal Service

Customer Name

 

0MB No. 1535-0138
FS Form 5446 (revised February 2017)

Treasury Direct® Offline Transaction Request

fraudulent claim or statement to the United States is a en me that

 

Use this form to request transactions that involve a Treasury Direct account and cannot be completed online. If a ...
*     Decedent's estate is involved, see the Instructions for examples of when this form may or may not be used.
*     Change to an Entity Account or Entity Account Manager is invofvedf see tfie Instructions for additional evidence that may be required.
Carefully read all of the Instructions before completing this form and complete only the parts of the form that apply to the transactions) requested. Parts A and F must be completed for ALL transactions.
At a glance ...________

then complete parts

 

A, E-1, and F
Change or correct account name

Correct Social Security Number
A, E-1, and F
Account owner or parent of a minor account owner
None required.
Correct date of birth
A, E-1, and F

 

Remove hardlock
A and F

 

Account owner or parent of a minor account owner and the security is a restricted, converted security
If the non-converting coowner or beneficiary is deceased, a certified copy of his or her death certificate.
Transfer
A, C, and F
Edit
A, D-1, and F

 

Suiviving secondary owner or beneficiary, including non-converting coowner or beneficiary
Redemption
A, B, and F
A certified copy of the decedent's death certificate.
Transfer
A, C, and F

 

Non-converting coowner or beneficiary
Edit registration
A, D-1, and F
None required.

 

Redemption
A, B, and F
Legal representative or legal guardian formally appointed by the court and still acting
A certified copy of your letters of appointment, dated within one year of submission.
Transfer to a TreasuryDirect Entity Account, financial institution, or broker
A, C, and F

 

Redemption
A, B, and F
Transfer to person(s) entitled
A, C, and F
Person entitled to securities due to distribution of an estate by a legal representative or restoration to competency or attainment of majority when a legal guardian has been formally appointed

A certified copy of the legal representative's or legal guardian's letters of appointment dated within one year of submission, certified copies of death certificates for all deceased registrants, and a FS Form 1455 showing distribution.

1
FS Form 5446
Department of the Treasury | Bureau of the Fiscal Service
Redemption
A, B, and F
A copy of the power of attorney document, containing the grantor's signature and witnessed or certified in accordance with applicable state law.
Transfer
A, C, and F
Edit registration
A, D-1, and F
Attorney-in-fact
Change or correct account name
A, E-1, and F
Correct Social Security Number
A, E-1, and F

 

Correct date of birth
A, E-1, and F

 

A certified copy of the court approved document authorizing the transaction.
Redemption
A, B, and F
Person(s) entitled through judicial proceedings
Transfer to person(s) entitled
A, C, and F

 

Person entitled to securities belonging to a decedent's estate when a legal representative has not been/ will not be appointed and the estate is not being settled in accordance with state statute
Redemption
A, B, and F
A certified copy of the decedent's death certificate and properly completed FS Form 5336 showing distribution.
Transfer to person(s) entitled
A, C, and F

 

Change or correct Entity Account information
A, E-2, and F
Copy of trust, corporate resolution, letters of appointment, death certificate, etc., as applicable. See Instructions.
Entity Account Manager or new Entity Account Manager
Change or correct Entity Account Manager information
A, E-2, and F
Change or correct Entity Account Manager___
A, E-3, and F
Copy of trust, corporate resolution, letters of appointment, death certificate, etc., as applicable. See Instructions.
Currently acting Entity Account Manager
Change of Entity Account Manager
A, D-2, and F

 

FS Form 5446
Department of the Treasury | Bureau of the Fiscal Service

Part A

 

Account and Transaction Information
1.   Treasury Direct Account Information TreasuryDirect Account Number:
TreasuryDirect Account Name:
Taxpayer Identification Number (SSN or EIN)
2.   Transactions Requested (Check all that apply.)
	
	3Ct
one :>r

	rxeuempuuri ui ciz ur i savings uurius neiu in
~l~r.&.^^i i r\ f l~^ i r.o ^4-
	Transfer of an EE or 1 savings bond from one TreasuryDir*

——     i i caoui y i_/m col.
	- account to another. Complete Part C-1 .

	Redeem C of 1.
	Transfer of a Treasury bill, note, bond, FRN, or TIPS from

	- TreasuryDirect account to another. Complete Part C-1 . Transfer of a Treasury bill, note, bond, FRN, or TIPS from

	tan me registration ot existing tt or i savings oonas neia
	TreasuryDirect to a financial institution or brokerage firm fc

If!   I lt?cti>UI yLJIICUL.
	safekeeping or sale. Complete Part C-2.

	Change or correct account owner's name.
	Remove hard lock.

	

	Change or correct Entity Account information.
	Other (specify).

	Correct account owner's Social Security Number. Change or correct Entity Account Manager information. Correct account owner's date of birth.

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

3.    Capacity of Applicant(s) (Check all that apply.) (Supporting evidence is often required; see the Instructions.) Individual Account Owner Entity Account Manager Surviving secondary owner or beneficiary Non-converting coowner or beneficiary
Legal representative of the estate of
Legal guardian of the estate of ___________________
Person(s) entitled as shown on FS Form 1455
Parent of a minor account owner
Attorney-in-fact
Person(s) entitled through judicial proceedings
Person(s) entitled to decedent's estate as shown on FS Form 5336
Other (specify)

FS Form 5446
Department of the Treasury | Bureau of the Fiscal Service

PartB

 

Redeem EE or I Savings Bonds Held in TreasuryDirect
Complete a separate Part B for each separate redemption request and/or if the number of savings bonds to be redeemed is more than can be described in the space provided.

I request redemption of the following 1.   Description of Savings Bonds

or I savings bonds held in TreasuryDirect,

Redeem ALL my savings bonds in the requested TreasuryDirect account.

Redeem only the savings bonds listed by confirmation number below.

Confirmation Numbers

 

Redeem C of I to the extent of $

2.   Payee Information

 

(Name)

OR
(Social Security Number)
(Employer Identification Number)

3.   Direct Deposit Instructions
request that the proceeds from the redemption be deposited to:

(Name[s] on the Account)

Type of Account:   _ Checking  _ Savings

(Depositor's Account No.)

Bank Routing No.:

 

(Financial Institution's Name)
(Phone Number)

 

FS Form 5446
Department of the Treasury | Bureau of the Fiscal Service

Part C-1

 

Transfer Securities from One TreasuryDirect Account to Another
Complete a separate Part C-1 for each separate transfer request and/or if the number of securities to be transferred is more than can be described in the space provided.
I request/consent to transfer as indicated in Item 2 the following securities held in TreasuryDirect.
By submitting this form, I certify that I understand the securities described will be removed from the originating account and transferred to the recipient's TreasuryDirect account. I also understand the registration of the transferred securities ill be changed to show the owner of the account receiving the securities as the single owner.
If this is a savings bond transaction, I certify that this transfer is either for the purpose of making a gift or is in response to a final judgment, court order, divorce decree, or property settlement agreement. (NOTE: When you buy savings bonds in TreasuryDirect, you must hold them for at least five business days before you can transfer them to other accounts.)
If this is a marketable security transaction, I understand that all scheduled reinvestments related to this security/these securities will be canceled at the time of the transfer.
NOTES: 1. Series EE and Series I savings bonds may not be split. Each bond must be transferred in its entirety. Marketable securities may be transferred in full or in increments of $100. 2. If you are requesting transfer of savings bonds to a trust, carefully read and complete Page 6.
TAX LIABILITY: I certify that I understand this transaction may be reported to the Internal Revenue Service and that this transfer may result in a tax liability.
1.   Description of Securities

Transfer ALL securities in the requested TreasuryDirect account.

Confirmation Number

 

Transfer of security in FULL
OR Transfer of security to the extent of $
Transfer of security in FULL
OR Transfer of security to the extent of $
Transfer of security in FULL
OR Transfer of security to the extent of $
Transfer of security in FULL
OR Transfer of security to the extent of $

2.   Transfer Instructions

Transfer security(ies) to:
TreasuryDirect Account Number: TreasuryDirect Account Name:

Taxpayer Identification Number (SSN or EIN):

Mark this box if the transfer is between spouses or incident to a divorce.

FS Form 5446
Department of the Treasury | Bureau of the Fiscal Service

Part C-1 (continued)

Upon the transfer of savings bonds to a trust, you must include in your gross income any accumulated interest on the bonds, if you have not already reported it, unless, under the grantor trust provisions of the Internal Revenue Code, you are treated as the owner of the portion of the trust represented by any tax-deferred accumulated interest on the transferred bonds. If you are treated as the owner of that portion, the accumulated interest continues to be your income rather than that of the trust, and therefore, you may continue to defer reporting the interest earned each year. You must include the total accumulated interest in your gross income when the bonds are disposed of or finally mature, whichever is earlier. These rules apply when bonds being transferred are Series I bonds or Series EE bonds, if you are the owner of the portion of the trust represented by the tax-deferred accumulated interest.
Generally, you will be treated as the owner of a trust that you have created to the extent that you retain certain powers over or interests in the trust. For example, you will be treated as the owner of the portion of the trust represented by any tax-deferred accumulated interest on the transferred bonds under the following circumstances:
(1) You will be treated as the owner of a trust to the extent that you have an unconditional power to revest in yourself title to the trust assets. Thus, if you can, at your discretion, revoke all or part of the trust so that the bonds will be returned to you, you will be treated as the owner of the portion of the trust represented by any accumulated interest on the bonds.
(2)  If the trust instrument provides that the transferred bonds or the proceeds from the redemption or disposition of those bonds must be distributed to you or your spouse, or held or accumulated for future distribution to you or your spouse, you will be treated as the owner of the portion of the trust represented by any accumulated interest on the bonds. You will be treated as the owner in this circumstance irrespective of the terms of the trust.
(3) You will be treated as the owner of a trust to the extent that you retain a power to control the beneficial enjoyment of property transferred to a trust. Thus, if you retain, under the terms of the trust instrument, an immediately exercisable power to determine, in your sole discretion, who will receive the bonds or the proceeds from the redemption or disposition of the bonds, then you will be treated as the owner of the portion of the trust represented by any accumulated interest.
The examples outlined above are illustrative only and they are not intended to cover all possible situations in which you could be treated as the owner of a trust or a portion of a trust. Furthermore, events can occur, such as the renunciation of a retained power or interest, which would cause you to cease being treated as the owner of a trust. If you are not sure whether you will be treated as the owner of a trust, you may request a letter ruling from the Internal Revenue Service. A request for a letter ruling should be sent to: Internal Revenue Service, ATTN: CC: DOM: CORP: T, PO Box 7604, Ben Franklin Station, Washington, DC 20044.
If you have questions concerning the information to be submitted in connection with a letter ruling request, you may call 202-317-4782._______________________________________________________________
For Federal income tax purposes:
a.   ~   I certify that I will be treated as owner of the portion of the trust represented by the tax-deferred accumulated
interest on the bonds being transferred. If this box is marked, the interest will be tax-deferred (interest will not be reported to the Internal Revenue Service as a result of the transfer).
b.   ~   I certify that I will not be treated as owner of the portion of the trust represented by the tax-deferred
accumulated interest on the bonds being transferred. If this box is marked, interest will be reported to the Internal Revenue Service for the taxable year in which the bonds were transferred to the trust. A 1099-1 NT wilt be generated for the Social Security Number specified.
FS Form 5446	Department of the Treasury | Bureau of the Fiscal Service                                                             6

Part C-2

 

Transfer Treasury Bills, Notes, Bonds, FRNs, or TIPS From TreasuryDirect to a Financial Institution or Brokerage Firm for Safekeeping or Sale
Complete a separate Part C-2 for each separate transfer request and/or if the number of securities to be transferred is more than can be described in the space provided.
I request/consent to transfer out of TreasuryDirect the following Treasury bills, notes, bonds, FRNs, or TIPS, as indicated in Item 2. I understand that all scheduled reinvestments related to this security/these securities will be canceled at the time of the transfer.
1.   Description of Securities__________________________________________________

Transfer ALL my securities in the requested TreasuryDirect account.

Confirmation Number

 

Transfer of security in FULL OR
Transfer of security to the extent of $
Transfer of security in FULL
OR Transfer of security to the extent of $
Transfer of security in FULL OR
Transfer of security to the extent of $
Transfer of security in FULL OR
Transfer of security to the extent of $

2.   Transfer to a Financial Institution or Brokerage Firm (does NOT apply to savings bonds)
authorize the Treasury Department to remove the securities described on this page from my control within the TreasuryDirect system and transfer them to the financial institution or brokerage firm designated below. I further understand that this transaction may be rejected or its processing delayed, if I provided incorrect information and/or submitted the transaction immediately prior to a Closed Book Period. I certify that I have the authority to request this transaction.
NOTE: Failure to provide any of the following information could delay the transfer. See instructions before completing.

Routing Number:
Financial Institution Wire Name:

Agent or Broker Name:
Agent or Broker Phone Number:

Agent or Broker Address:

 

Special Handling Instructions:

 

Mark this box if the transfer is between spouses or incident to a divorce.

FS Form 5446
7
Department of the Treasury | Bureau of the Fiscal Service
Part D-1

 

it the Registration of Securities Held in TreasuryDirect
Complete a separate Part D-1 for each new registration requested and/or if the total number of securities being edited is more than can be described in the space provided.
I request/consent to edit as indicated in Item 2 the registration of the following securities held in TreasuryDirect. 1.   Description of Securities

Edit the registration of ALL securities in the requested TreasuryDirect account.

Issue Date of
Confirmation Number
Registration

 

2.   New Registration Requested
Owner/Primary Owner:   ___

(First Name / Middle Name or Initial / Last Name)

Social Security Number:
(required)

 

Secondary owner Beneficiary
The following person is to be named as:

Name:
(First Name / Middle Name or Initial / Last Name)

(required)
Social Security Number:

 

FS Form 5446
8
Department of the Treasury | Bureau of the Fiscal Service

Part D-2

 

Consent to Change the Entity Account Manager of a Treasury Direct Account
Complete Part D-2 to consent to a change of Entity Account Manager for a TreasuryDirect account.
I ________________________         ______________________ hereby authorize
(Name of Entity Account Manager consenting to the change)
the Bureau of the Fiscal Service, Parkersburg, West Virginia, to remove my personal information as the Entity Account Manager for _____________________         _______________________
(TreasuryDirect Entity Account Name)

and change the Entity Account Manager to

(Name of New Entity Account Manager)

FS Form 5446	Department of the Treasury | Bureau of the Fiscal Service                                                              9

Part E-1

 

Change or Correct Account Information For an Individual Treasury Direct Account
1.   Change an Individual Account Owner's Name
certify that the account owner's name has been legally changed by:

Marriage
Divorce
Adoption
Naturalization
Court order

Other (explain)

 

to
(Furnish the New Legal Name)

 

2.   Correct an Individual Account Owner's Name
certify that the account owner's name is incorrectly shown on the account.
The account owner's correct legal name is:
3.  Correct an Individual Account Owner's Social Security Number
I certify that the account owner's Social Security Number is incorrectly shown on the account. The account owner's correct Social Security Number is: ___________________
4.   Correct an Individual Account Owner's Date of Birth
certify that the date of birth shown for the account owner on the Treasury Direct account is incorrect and that the account owner's correct date of birth is:

(Month/Day/Year)

 

10
FS Form 5446
Department of the Treasury | Bureau of the Fiscal Service
Part E-2

Change or Correct the Entity Account Information
1. Change Entity Account Name
certify that the Entity Account name has changed to
Provide an explanation for the change:
2. Correct Entity Account Name
certify that the Entity Account name is incorrectly shown on the account.
The correct account name is:
3. Correct Entity Account Taxpayer Identification Number
certify that the Entity Account Taxpayer Identification Number (EIN or SSN) is incorrectly shown on the account.
The correct account Taxpayer Identification Number is:
FS Form 5446	Department of the Treasury | Bureau of the Fiscal Service                                                            11

Part E-2 (continued)

 

Change or Correct the Current Entity Account Manager Information
1. Change Entity Account Manager's Name
certify that the Entity Account Manager's name has been legally changed by

Marriage	_ Divorce              _ Naturalization             _ Court order

Other (explain):

 

to:
(Furnish the New Legal Name)

 

2. Correct Entity Account Manager's Name
certify that the Entity Account Manager's name is incorrectly shown on the account. The correct Entity Account Manager's legal name is:

(First/Middle/Last)

 

3. Correct Entity Account Manager's Social Security Number
certify that the Entity Account Manager's Social Security Number is incorrectly shown on the account.
The correct Entity Account Manager's Social Security Number is:
4. Correct Entity Account Manager's Date of Birth
certify that the Entity Account Manager's date of birth is incorrectly shown on the account.

(Month/Day/Year)
The Entity Account Manager's correct date of birth is:

FS Form 5446	Department of the Treasury | Bureau of the Fiscal Service                                                            12

Part E-3

 

Change Entity Account Manager - New Manager Information

1. Account Manager Name:
(First Name / Middle Name or Initial / Last Name / Suffix)

2. Taxpayer Identification Number:

(Social Security Number of New Entity Account Manager)

3. Date of Birth:

(Month/Day/Year)

4. Street Address:

 

5. City:
State:
Zip Code

6. Home Phone: Work Phone:

 

Cell Phone:

 

7. Driver's License/State ID Number: Issuing State:       _________

Expiration Date: 8. E-mail Address

 

9. Mailing Address (check one):

Use the Entity Address
Use the Account Manager Address

n support of the Entity Account Manager change requested above, evidentiary documentation must also be provided to explain why the change is being requested. For example, the evidence necessary may include a certified copy of:
•	the trust document, if a successor trustee will be the new account manager
•	a letter of resignation, if the current administrator, legal representative, or trustee resigned
•	the new partnership agreement, if a member left the partnership or is stepping down as the account manager
•	the corporate resolution or articles of organization, if the company reorganized or officers have changed
•	the letters of appointment, if a new guardian or legal representative has been appointed
•	a death certificate, if the current Entity Account Manager is deceased
NOTE: The current Entity Account Manager must complete Parts A and D-2 and sign in Part F.  If he or she is unable to sign, please provide evidence as to why—evidence such as a certified copy of a death certificate.

13
FS Form 5446
Department of the Treasury | Bureau of the Fiscal Service

PartF

 

Signatures and Certifications
The undersigned certify under penalty of perjury that the information provided herein is true and correct to the best of our knowledge and belief and agree to distribution of the securities as indicated. We bind ourselves, our heirs, legatees, successors and assigns, jointly and severally, to hold the United States harmless on account of the transaction requested, to indemnify unconditionally and promptly repay the United States in the event of any loss which results from this request, including interest, administrative costs, and penalties. We consent to the release of any information regarding this transaction, including information contained in this application, to any party having an ownership or entitlement interest in the securities or checks.

^

 

Sign Here:
(Signature)
(E-mail Address)

 

(Mailing Address)
(Daytime Phone No.)

Sign Here:
(Signature)
(E-mail Address)

 

(Mailing Address)
(Daytime Phone No.)

 

mill

 

^11^!^^
g::^

whose identity is known or was
CERTIFY that
(Name of Person Who Appeared)

day of
(Month/Year)
proven to me, personally appeared before me this

and signed this form.
at __________________
(City, State)

(Signature and Title of Certifying Officer)

(Name of Financial Institution)

 

(Address)

 

(City, State, ZIP Code)

 

(Telephone)

 

14
FS Form 5446
Department of the Treasury | Bureau of the Fiscal Service
whose identity is known or was
CERTIFY that
(Name of Person Who Appeared)

(Month/Year)
proven to me, personally appeared before me this _____________ day of

at ______________________________ , and signed this form.
(City, State)
(Signature and Title of Certifying Officer)
(Name of Financial Institution)
(Address)
(City, State, ZIP Code)
(Telephone)
FS Form 5446	Department of the Treasury | Bureau of the Fiscal Service                                                           15
Complete only the parts of the form that apply to the transactions) requested.
Use of Form - Use this form to request transactions that involve a TreasuryDirect account and cannot be completed online. Complete a separate FS Form 5446 for each TreasuryDirect account number.
If a decedent's estate is involved, this form may be used ONLY in the following cases:
•     A legal representative has been appointed and is still acting and the legal representative wishes to redeem securities. The legal representative must use a FS Form 1455 to distribute the securities to the persons entitled. The persons entitled may then use this form to request transfer or payment of securities. In order to sell unmatured Treasury bills, notes, bonds, FRNs, or TIPS, the security must be transferred to a financial institution or brokerage firm.
• A legal representative has not been appointed to settle the decedent's estate but the person entitled to the securities wishes to request transfer or payment of securities. (Use an FS Form 5336 to distribute the securities to the person[s] entitled if the redemption value of all securities owned by the decedent does not exceed $100,000. Estates with securities valued over $100,000 must be formally administered through the court and an administrator, executor, or similar representative appointed.) In order to sell unmatured Treasury bills, notes, bonds, FRNs, or TIPS, the security must be transferred to a financial institution or brokerage firm. If a decedent's estate is involved, this form may NOT be used in the following cases:
•     The decedent's estate was formally administered through the court and has been closed (use FS Form 5394).
•     The decedent's estate is being settled in accordance with State statute such as Summary Administration, Small Estates Acts, Texas Muniment of Title, Louisiana Judgment of Possession, etc., without the necessity of the court appointing an administrator, executor, or similar legal representative (use FS Form 5394).

 

1. TreasuryDirect Account Information - Provide the TreasuryDirect account number, account name, and Taxpayer Identification Number (Social Security Number or Employer Identification Number).
2. Transactions Requested - Mark the appropriate box to show the type of transaction requested.   You can mark more than one box, if multiple transactions are requested.
3. Capacity of Applicant(s) - Mark the box that best describes the capacity in which you are acting. You can check more than one box, if applicable. Provide any necessary evidence, as described below:

 

Individual Account Owner or parent of a minor account owner, and the security is a restricted, converted security

If the non-converting coowner or beneficiary is deceased, a certified copy of his or her death certificate.

Entity Account Manager
A copy of the evidence that establishes your authority to request the transaction. If filed with a court, the evidence must be under court seal. For example: copy of trust, corporate resolution, letters of appointment, death certificate, etc., as applicable.

Surviving secondary owner or beneficiary including non-converting coowner or beneficiary

A certified copy of the decedent's death certificate.

Legal representative
A certified copy of your letters of appointment, dated within one year of submission.

Legal guardian
Person(s) entitled as shown on FS Form 1455

A certified copy of your letters of appointment, dated within one year of submission.________________________
A certified copy of the legal representative's or legal guardian's letters of appointment dated within one year of submission, certified copies of death certificates for all deceased registrants, and a FS Form 1455 showing distribution.____________

Attorney-in-fact
A copy of the power of attorney document, containing the grantor's signature and witnessed or certified in accordance with applicable State law.

Person(s) entitled through judicial proceedings
(The persons shown to be entitled are making this request in connection with a legal proceeding or court order [such as divorce decree, court-approved property settlement agreement, levy, money judgment, bankruptcy proceeding] involving the owner/primary owner of the securities in TreasuryDirect.)

A certified copy of the court approved document authorizing the transaction.

16
FS Form 5446
Department of the Treasury | Bureau of the Fiscal Service
Person(s) entitled to decedent's estate as shown on FS Form 5336
A certified copy of the decedent's death certificate and properly completed FS Form 5336 showing distribution.

Other
A copy of the evidence that establishes your authority to request the transaction.  If filed with a court, the evidence must be under court seal.

1. Description of Savings Bonds - Check either the box to redeem all savings bonds or the box to redeem only some of your savings bonds. If you are redeeming only some, list the confirmation number for each savings bond you are asking us to redeem. Check the third box if you want to redeem your C of I, and state the amount you want to redeem.
Important Notices
•     Only original signatures will be accepted (stamped signatures are not acceptable).
•     If you are a corporation with a governing body, a resolution or a FS Form 1010 must accompany this form.
•     If any person signing this form is acting in a fiduciary capacity, failure to provide legal evidence may delay processing.
This form will not be accepted with alterations or corrections.
2. Payee Information - Furnish the name and taxpayer identification number of the payee. Furnish the Social Security Number if the payee is an Individual. If payment is being requested to an estate and the IRS has assigned an Employer Identification Number, provide that number.___________________________________________
3. Direct Deposit Instructions - Furnish information on the bank account where the payment is to be direct deposited. All payments must be made by direct deposit to a designated bank account.
All persons requesting redemption must sign in Part F of the form. If payment is to be deposited to a bank account in the name of a different person, then that person or his or her representative, who can authorize such a deposit, must also sign in Part F.

 

Part C-1 - Transfer Securities from One Treasury Direct Account to Another TreasuryDirect Account
1. Description of Securities - Check the box to transfer all securities or list the confirmation number for each security to be transferred. Series EE and Series I savings bonds may not be split. Each savings bond must be transferred in its entirety. Marketable securities may be transferred in full or in increments of $100. For each marketable security listed, indicate whether you are requesting transfer in full or in part by checking the appropriate box in the column next to the security confirmation number. If you don't check either box, we'll assume transfer in full.
NOTE:   The amount to be transferred and the amount remaining in the CUSIP must satisfy both the minimum and multiple holding requirements for the security.
2. Transfer Instructions:
•     TreasuryDirect Account Number - Enter the number of the account to which the securities are being transferred. If you are the legal representative of a decedent's estate transferring securities to the person entitled, and he/she does not have a TreasuryDirect account and does not wish to open one, show "none" in the space for the account number.
•     TreasuryDirect Account Name - Enter the account name or the name of the person entitled.
•     Taxpayer Identification Number - Enter the Taxpayer Identification Number (Social Security Number or Employer Identification Number) of the Individual or Entity entitled.
•     Mark this Box. If you don't mark this box, we will assume the transfer is neither between spouses nor incident to a divorce.

17
FS Form 5446
Department of the Treasury | Bureau of the Fiscal Service
3. Tax Liability Notice - Carefully read this section before completing Item 4.
4. Tax Liability Statement - After reading the Tax Liability Notice in Item 3, you must mark box "a" or "b" in Item 4 Mark box "a" if you will be treated as the owner of the portion of the trust represented by the tax-deferred accumulated interest on the bonds being transferred. Mark box "b" if you will NOT be treated as owner of the portion of the trust represented by the tax-deferred accumulated interest on the bonds being transferred. "Interest" includes tax-deferred interest earned on EE or I bonds from the issue date until the date of transfer.
Part C-2 - Transfer Treasury Bills, Notes, Bonds, FRNs, or TIPS from TreasuryDirect to a Financial Institution or Brokerage Firm for Safekeeping or Sale
1.  Description of Securities - Check the box to transfer all securities or list the confirmation number for each security that you are requesting transfer of in whole or in part. For each security listed, indicate whether you are requesting transfer in full or in part by checking the appropriate box in the column next to the security confirmation number; if you don't check either box, we will assume transfer in full.
If partial transfer is requested, check the appropriate box and specify the amount you are requesting be transferred. Enter only the amount being transferred (in $100 increments) and list the confirmation number. NOTE: The amount to be transferred and the amount remaining in the CUSIP must satisfy both the minimum and multiple holding requirements for the security.
2. Transfer Instructions - Contact the financial institution for its 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 the financial institution receiving the securities.
•     Financial Institution Wire Name - The 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 or Broker Name, Phone Number, Address.
•     Special Handling Instructions - The customer name and account number at the financial institution for delivery of securities and any other instructions required by your financial institution.
•     Mark this Box. If you don't mark this box, we will assume the transfer is neither between spouses nor incident to a divorce.
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	Special Handling Instructions:	FURTHER CREDIT TO JOHN DOE
TRUST ACCOUNT NUMBER XXXXXX	BROKERAGE ACCOUNT NUMBER
XXXXXX
Note: All scheduled reinvestments will be cancelled at the time of transfer.
FS Form 5446	Department of the Treasury | Bureau of the Fiscal Service                                                            18

Part D-1 - Edit the Registration of Securities Held in Treasury Direct
1. Description of Securities - Check the box to edit the registration of all securities or describe the securities on which you want to edit the registration.
2. New Registration Requested - Provide the complete name and Social Security Number of the owner/primary owner. The account owner must be named as the owner/primary owner in the registration of the securities held in his or her TreasuryDirect account. If a secondary owner or beneficiary is to be shown in the registration, check the appropriate box and provide the name and Social Security Number of the person to be shown as the secondary owner or beneficiary.
Part D-2 - Consent to Change the Entity Account Manager of a TreasuryDirect Account
•     Name of the Entity Account Manager consenting to the change - Enter the name of the currently acting Entity Account Manager.
•     TreasuryDirect Entity Account Name - Enter the name of the Entity (i.e., trust, partnership, corporation, deceased estate) as it appears on the TreasuryDirect account.
•     Name of the new Entity Account Manager - Enter the name of the individual who will be acting as the new Entity Account Manager.
•     Sign the form in Part F in ink, in the presence of an authorized certifying officer.
The new Entity Account Manager will need to provide his or her personal information on Part E-3 of FS Form 5446 and join in signing the form in Part F in the presence of an authorized certifying officer.
Part E-1 - Change or Correct an Individual Account Information
The following information must be provided by the Individual Account Owner
1. Change an Individual Account Owner's Name - Complete this item if the account owner's name has changed by marriage, divorce, adoption, naturalization, court order, or some other valid reason. Indicate the manner by which the name changed and furnish the account owner's new legal name. Evidence may be required.
2. Correct an Individual Account Owner's Name - Complete this item if an error was made in the account owner's name when the TreasuryDirect account was established. Furnish the account owner's correct legal name.
3. Correct an Individual Account Owner's Social Security Number - Complete this item if an error was made in the account owner's Social Security Number when the TreasuryDirect account was established. Furnish the account owner's correct Social Security Number.
4. Correct an Individual Account Owner's Date of Birth - Complete this item if an error was made in the account owner's date of birth when the TreasuryDirect account was established. Furnish the account owner's correct date of birth.
Part E-2 - Change or Correct Entity Account Information
The following information must be provided by the Entity Account Manager
1. Change Entity Account Name - Complete this item if the name of the Entity has changed. Provide an explanation for the name change.
2. Correct Entity Account Name - Complete this item if the Entity Account name has been entered incorrectly.
3. Correct Taxpayer Identification Number - Complete this item if the taxpayer identification number for the Entity was entered incorrectly.
Change or Correct Current Entity Account Manager Information
The following information must be provided by the Entity Account Manager
1. Change Entity Account Manager's Name - Complete this item if the Entity Account Manager's name has changed by
FS Form 5446	Department of the Treasury | Bureau of the Fiscal Service                                                         19

marriage, divorce, adoption, naturalization, court order, or some other valid reason.   Indicate the manner by which the name changed and furnish the Entity Account Manager's new legal name. Evidence may be required.
2. Correct Entity Account Manager's Name - Complete this item if an error was made in the Entity Account Manager's name when the Treasury Direct account was established. Furnish the Entity Account Manager's correct legal name.
3. Correct Entity Account Manager's Social Security Number - Complete this item if an error was made in the Entity Account Manager's Social Security Number when the TreasuryDirect account was established. Furnish the Entity Account Manager's correct Social Security Number.
4. Correct Entity Account Manager's Date of Birth - Complete this item if an error was made in the Entity Account Manager's date of birth when the TreasuryDirect account was established. Furnish the Entity Account Manager's correct date of birth.
Part E-3 - Change Entity Account Manager - New Manager Information
The following information must be provided by the new Entity Account Manager
1. Account Manager Name - Enter the new Entity Account Manager's full name including suffix, if appropriate.
2. Taxpayer Identification Number - Enter the new Entity Account Manager's Social Security Number.
3. Date of Birth - Enter the new Entity Account Manager's date of birth.
4. Street Address - Enter the new Entity Account Manager's home street address.
5. City/State/Zip Code - Enter the new Entity Account Manager's home address city, state and zip code.
6. Phone - Enter the home, work and cell telephone number for the new Entity Account Manager.
7. Driver's License/State ID Number - Enter the driver's license or state ID number, including the issuing state and expiration date, for the new Entity Account Manager.
8. E-mail Address - Enter the e-mail address the new Entity Account Manager wishes to use to communicate with TreasuryDirect. This e-mail address will be used for important messages from the TreasuryDirect system and for communication from within the TreasuryDirect account.
9. Mailing Address - Indicate the mailing address TreasuryDirect Customer Service should use if it is necessary to mail correspondence to the new Entity Account Manager by postal mail.
The new Entity Account Manager must sign the form in Part F in the presence of an authorized certifying officer.
Signatures/Certifications - Each applicant must appear before and establish identification to the satisfaction of an authorized certifying officer and sign the application in the officer's presence. The officer must then complete the certification form provided and imprint the seal or stamp required in certifying requests. For certifications within the United States, the certifying officer must be authorized to bind his or her institution by his or her acts and guarantee signatures to assignments of securities or certify assignments of securities. Certification by a notary isn't acceptable.
If you are a parent of a minor account owner, your signature certifies that you are requesting the transaction on the minor's behalf, for the minor's benefit.
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.
FS Form 5446	Department of the Treasury | Bureau of the Fiscal Service                                                                   20
Sample certification for a financial institution
SIGNATURE GUARANTEED
ABC National Bank
Hillview Branch
Acceptable certification for a brokerage:
SIGNATURE GUARANTEED
MEDALLION GUARANTEED
Generic Brokerage

Authorized Signature
Authorized Signature
xxxxxxxx
SECURITIES TRANSFER AGENTS MEDALLION PROGRAM
[Bar Code]

Additional Evidence - The Commissioner of the Fiscal Service, as designee of the Secretary of the Treasury, reserves the right, in any particular case, to require the submission of additional evidence.
Assembly of Form - Complete and submit only the parts of the form that apply to the transaction(s) requested. Parts A and F must be completed and submitted for all transactions. Multiple copies of any part may be completed and submitted together, if necessary. Attach all completed parts together, in alphabetical order.
Where To Send - Send all completed parts of the form, as well as any other forms and evidence, to the address below. Legal evidence or documentation you submit cannot be returned.
Treasury Retail Securities Site
PO Box 7015
Minneapolis, MN 55480-7015
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 30 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 the completed form to this address; send to the address shown in "Where To Send" in the Instructions.

FS Form 5446
21
Department of the Treasury | Bureau of the Fiscal Service

II

:;*:*:*>

 

FS Form 5179 (revised June 2016)
OMBNo. 1530-0042

BUREAU OF THE
®
Legacy Treasury Direct  Security Transfer Request

SEE INSTRUCTIONS -TYPE OR PRINT IN INK ONLY - NO ALTERATIONS OR CORRECTIONS

1. Legacy Treasury Direct ACCOUNT INFORMATION

DOCUMENT AUTHORITY
Legacy Treasury Direct ACCOUNT NUMBER: ACCOUNT NAME

APPROVED BY

 

DATE APPROVED

 

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
CUSIP
AMOUNT

$
$ $
$
$ $ $ $

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 ACCOUNT NAME

NOTE: This must be an existing account; new accounts aren't available.

Identify the Legacy Treasury Direct account to which you want your securities transferred.

 

TAXPAYER IDENTIFICATION NUMBER (IF AVAILABLE)
First-Named        ___ Owner
OR
Social Security Number
Employer Identification Number

TRANSFER TO AN ESTABLISHED ONLINE Treasury Direct ACCOUNT NUMBER

TreasuryDirect ACCOUNT NUMBER ACCOUNT NAME

(May be established atwww.treasurydirect.gov.)

Identify the
TreasuryDirect account to which you want your securities transferred.

 

TAXPAYER IDENTIFICATION NUMBER (IF AVAILABLE)
First-Named        ___ Owner
OR
Social Security Number
Employer Identification Number

 

1
FS Form 5179
Department of the Treasury | Bureau of the Fiscal Service
EXTERNAL TRANSFER TO A FINANCIAL INSTITUTION

NOTE:  Failure to provide any of the following information could delay the transfer. See instructions before completing

ROUTING NUMBER:

 

PHONE NO.
FINANCIAL INSTITUTION WIRE NAME: AGENT or BROKER NAME:

AGENT or BROKER ADDRESS:

 

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.

Title (if appropriate)
Signature
Telephone (Daytime)

Title (if appropriate)
Signature

 

Mailing Address
E-mail Address

 

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.

certify that
Name(s) of Person(s) Who Appeared

, whose identity(ies) is/are known or proven to me,

in the year
day of
Year
Month
personally appeared before me this

, and signed this request.
at
City/State

Signature and Title of Certifying Officer

Name of Financial Institution

Address
City/State/ZIP Code

 

Telephone

Certification by a Notary is NOT Acceptable.

FS Form 5179
Department of the Treasury | Bureau of the Fiscal Service
INSTRUCTIONS
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 provided 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 the 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 account to which the securities are being transferred. If a new account has not yet been established, you can establish one atwww.treasurydirect.gov.
•      ACCOUNT NAME - Enter the ACCOUNT NAME (registration) 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.
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 the financial institution receiving the securities.

FINANCIAL INSTITUTION WIRE NAME - Provide 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, PHONE NUMBER, ADDRESS
SPECIAL HANDLING INSTRUCTIONS - The customer name and account number at the financial institution for delivery of securities; any other instructions required by your financial institution.

Examples: To a financial institution for safekeeping:
Routing Number:     XXXXXXXXX Financial Institution Wire Name:     ABC BK/TRUST Special Handling Instructions:      FURTHER CREDIT TO JOHN DOE
TRUST ACCOUNT NUMBER XXXXXX

To a financial institution for transfer to a brokerage firm:
Routing Number:     XXXXXXXXX Financial Institution Wire Name:     ABC/CUST/BRKG 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). In case there are questions about this transfer, please provide a mailing address, daytime telephone number, and, if applicable, e-mail address.

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

Acceptable certification for a brokerage:
SIGNATURE GUARANTEED
MEDALLION GUARANTEED
Generic Brokerage

Authorized Signature
Authorized Signature
xxxxxxxx
SECURITIES TRANSFER AGENTS MEDALLION PROGRAM _______________[Bar Code]_______________

WHERE TO SEND

If requesting a transfer to another Legacy Treasury Direct account or to a financial institution, mail this form to Treasury Retail Securities Site, PO Box 9150, Minneapolis, MN 55480-9150.
If requesting a transfer to an online Treasury Direct account, mail this form to Treasury Retail Securities Site, PO Box 7015, Minneapolis, MN 55480-7015.
To ensure timely processing, this form must be received at least ten business days in advance of:
•    the maturity date of the security
•    an interest payment date for the security
CONTACT
Call us toll-free in the United States at 844-284-2676. 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 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 10 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 completed form to this address; send to the appropriate address shown in "WHERE TO SEND" in the Instructions.

FS Form 5179
Department of the Treasury | Bureau of the Fiscal Service

I:*:*:
ii

::*:*:*::

 

 

INSTRUCTIONS
WHERE A WIRE TRANSFER HAS BEEN BLOCKED AT A U.S. FINANCIAL INSTITUTION DUE TO U.S. GOVERNMENT SANCTIONS, A PARTY TO THE TRANSFER MAY APPLY FOR RELEASE OF THE FUNDS.
•    COMPLETE ALL APPLICABLE SECTIONS.  FAILURE TO PROVIDE ADEQUATE INFORMATION MAY RESULT IN YOUR APPLICATION BEING RETURNED WITHOUT ACTION.
•    ATTACH COPIES OF ANY DOCUMENTS RELATED TO THE UNDERLYING TRANSACTION (E.G. INVOICES, BILLS OF LADING, PHOTOCOPY
OF THE ORIGINAL PAYMENT OR TRANSFER INSTRUCTIONS, COPIES OF GOVERNMENT-ISSUED IDENTIFICATION SUCH AS PASSPORT, TEMPORARY/PERMANENT RESIDENT CARD, BIRTH CERTIFICATE, OR OTHER IDENTIFYING DOCUMENTATION).
•    ALL DOCUMENTS MUST BE IN ENGLISH OR INCLUDE AN ENGLISH TRANSLATION.
•    MAIL THE COMPLETED AND SIGNED APPLICATION, TOGETHER WITH ACCOMPANYING DOCUMENTATION AND TWO ADDITIONAL COPIES OF THE ENTIRE SUBMISSION, TO: THE OFFICE OF FOREIGN ASSETS CONTROL, 1500 PENNSYLVANIA AVENUE,NW-ANNEX, WASHINGTON, D.C. 20220, ATTN: BLOCKED FUNDS APPLICATION
•    A COPY OF THIS APPLICATION AND ALL RELATED DOCUMENTATION MUST BE RETAINED BY THE APPLICANT FOR AT LEAST FIVE YEARS AFTER THE DATE OF THE UNDERLYING TRANSACTION.
•    UNLESS AUTHORIZED BY OFAC, APPLICATIONS MADE BY ANY OTHER METHOD WILL NOT BE CONSIDERED.
LICENSES GRANTED PURSUANT TO THIS APPLICATION ARE SUBJECT TO THE CONDITIONS BELOW
•    LICENSEES SHALL FURNISH AND MAKE AVAILABLE FOR INSPECTION ANY RELEVANT INFORMATION, RECORDS OR REPORTS REQUESTED BY THE SECRETARY OF THE TREASURY OR ANY DULY AUTHORIZED OFFICER OR AGENCY OF THE SECRETARY.
•    A SPECIFIC LICENSE IS NOT TRANSFERABLE, IS LIMITED TO THE FACTS AND CIRCUMSTANCES SPECIFIC TO THE APPLICATION, AND IS SUBJECT TO THE PROVISIONS OF 31 CFR PART 501, THE RELEVANT EXECUTIVE ORDER OR PART OF 31 CFR CHAPTER V PERTAINING TO THE SANCTIONS PROGRAM UNDER WHICH THE TRANSFER WAS BLOCKED AND ANY REGULATIONS OR RULINGS ISSUED PURSUANT THERETO. A LICENSE MAY BE REVOKED OR MODIFIED AT ANY TIME AT THE DISCRETION OF THE SECRETARY OF THE TREASURY.  IF A SPECIFIC LICENSE WAS ISSUED AS A RESULT OF WILLFUL MISREPRESENTATION ON THE PART OF THE APPLICANT OR HIS AGENT, IT MAY, AT THE DISCRETION OF THE SECRETARY OF THE TREASURY, BE DECLARED VOID FROM THE DATE OF ITS ISSUANCE, OR FROM
ANY OTHER DATE.
•    A SPECIFIC LICENSE 1) DOES NOT EXCUSE COMPLIANCE WITH ANY LAW OR REGULATION ADMINISTERED BY THE OFFICE OF FOREIGN
ASSETS CONTROL OR ANOTHER AGENCY (INCLUDING REPORTING REQUIREMENTS APPLICABLE TO THE TRANSACTIONS AND ACTIVITIES THEREIN LICENSED), 2) DOES NOT RELEASE THE LICENSEES OR THIRD PARTIES FROM CIVIL OR CRIMINAL LIABILITY FOR VIOLATION OF ANY LAW OR REGULATION, AND 3) DOES NOT CONSTITUTE A FINDING OF FACT OR CONCLUSION OF LAW WITH RESPECT
TO THE APPLICABILITY OF ANY LAW OR REGULATION.
•    ATTENTION IS DIRECTED TO 19 U.S.C. §§ 1592 AND 1595A, 18 U.S.C. § 545, 18U.S.C. §1001,50 U.S.C. APP. § 16, AND SECTION 701 ET SEQ. OF THE RELEVANT PART OF 31 CFR FOR PROVISIONS RELATING TO PENALTIES.
FOR YOUR INFORMATION
•	Remitter - The person or organization that is sending the funds.
•	Remitting Financial Institution -Name of the financial institution initiating the transfer on behalf of the remitter.
•	Intermediary Financial Institution - A bank other than the remitter's bank or beneficiary's bank through which the transfer passes.
•	Beneficiary Financial Institution - The financial institution receiving the funds on behalf of the beneficiary.
•	Beneficiary - The ultimate party to be credited or paid as a result of a wire transfer.
•   Hover Help - Holding the mouse cursor over the data entry portion of some fields will result in a pop-up box containing information on entering data into the field over which the mouse cursor is placed. This help also exists for the headings of each section.
WARNING!
MAKING FALSE OR MISLEADING STATEMENTS ON OR IN CONNECTION WITH THIS APPLICATION MAY CONSTITUTE SERIOUS CRIMINAL AND/OR CIVIL VIOLATIONS
OF FEDERAL LAW AND MAY RESULT IN SUBSTANTIAL FINES.
PAPERWORK REDUCTION ACT STATEMENT: The paperwork requirement has been cleared under the Paperwork Reduction Act of 1985. The Office of Foreign Assets Control (OFAC) of the Department of the Treasury requires this information to be furnished pursuant to 31 CFR Part 501. The information collected will be used for U.S. Government to evaluate and process license applications submitted by applicants whose money has been blocked pursuant to OFAC sanctions. It is the policy of OFAC to protect the confidentiality of information in appropriate cases pursuant to the exemptions from disclosure provided under the Freedom of Information Act and the Privacy Act. The estimated burden associated with this collection of information is 30 minutes per respondent. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Compliance Programs Division, Office of Foreign Assets Control, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220 and the Office of Management and Budget, Paperwork Reduction Project OMB No. 1505-0170, Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number assigned by OMB.
Mail this application to:   Licensing Division
Office of Foreign Assets Control U.S. Department of the Treasury
^r^nn	j       -a             m in/                                                                Form Approved
1500 Pennsylvania Avenue, N.W.	ombno^ 1505-0170
Washington, D.C. 20220	Expiration Date: 08/31/2012

0MB No. 1505-0170
Up Department of the Treasury
APPLICATION FOR THE RELEASE OF BLOCKED FUNDS
It is stmngly recommended that you use the computer to complete this form

Previous Case Number (if applicable):
TYPE OF APPLICATION New Application

1. Blocked Amount:
2. Currency Type:
3. Date Blocked (mm/dd/yyyy):

 

APPLICANT/CONTACT INFORMATION

4. Business Name (if applicable):
5. Last Name:
6. First Name:

 

7. Middle Name:
8a. Street Address 1:

 

8b. Street Address 2:
9. City:

 

10. Select Country
11. Select State
12. Postal Code:

 

Area	Exchange
	Number
	
	Extension

	

	
	
Area	Exchange
	Number

	

13. Int'l   14. Phone:
15. Int'l   16. Fax:

18. Principal Place of Business:
17. E-mail Address:

 

19. State or Country Where Business is Incorporated:
20. Transfer Blocked Due to the Following OFAC Sanctions Program: Select Program
IF BLOCKING OCCURRED BECAUSE THE NAME OF ANY PARTY TO THE TRANSACTION APPEARS TO MATCH A NAME ON THE SPECIALLY DESIGNATED NATIONALS (SDN) LIST, PLEASE PROVIDE INFORMATION RELATED TO THE NAME MATCH (e.g. copy of: original payment or transfer instructions, invoices, bills of lading, passport, temporary/permanent resident card, birth certificate, Employer Identification Number, passport, national ID card, incorporation document or other government-issued identifying documentation).
FINANCIAL INSTITUTION THAT BLOCKED FUNDS

21. Institution Name:
22. Street Address:
23. City:

 

24. Select Country
25.Select State
26. Postal Code:

 

REMITTER'S INFORMATION

27. Business Name (if applicable):
28. Last Name:
30. Middle Name:
29. First Name:

31. Street Address:
32. City:

 

34. Select State
33. Select Country
35. Postal Code:

 

REMITTING FINANCIAL INSTITUTION

36. Institution Name:
37. Street Address:
38. City:

 

39. Select Country
40.Select State
41. Postal Code:

 

Page 1 of 3
Total Barcode Characters: 342
 
0MB No. 1505-0170
APPLICATION FOR THE RELEASE OF BLOCKED FUNDS (cont'd)
INTERMEDIARY FINANCIAL INSTITUTION

42. Institution Name:
43. Street Address:
44. City:

 

45. Select Country
46 Select State
47. Postal Code:

 

BENEFICIARY FINANCIAL INSTITUTION

48. Institution Name:
49. Street Address:
50. City:

 

52 Select State
51. Select Country
53. Postal Code:

 

BENEFICIARY'S INFORMATION

54. Business Name (if applicable):
55. Last Name:
56. First Name:
57. Middle Name:

58. Street Address:
59. City:

 

60. Select Country
61 Select State
62. Postal Code:

 

63. DETAILED EXPLANATION OF THE TRANSACTION, INCLUDING THE PURPOSE OF THE PAYMENT (Additional space provided on next page.)

Page 2 of 3
Total Barcode Characters:   186
 
0MB No. 1505-0170

APPLICATION FOR THE RELEASE OF BLOCKED FUNDS (cont'd)
64. DETAILED EXPLANATION OF THE TRANSACTION (cont'd)
65. APPLICANT CERTIFICATION: I, THE UNDERSIGNED, HEREBY DECLARE THAT, TO THE BEST OF MY KNOWLEDGEJHE INFORMATION PROVIDED ON THIS APPLICATION AND ANY ACCOMPANYING DOCUMENTATION IS TRUTHFUL AND COMPLETE.
66. SIGNATURE:  (please provide handwritten signature on printed application)        67. DATE:        (please provide handwritten date)

68. SIGNATORY NAME:
69. SIGNATORY TITLE:

 

70. SIGNATORY E-MAIL:

 

Total Barcode Characters:   26

Total Barcode Characters:   27
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