To submit this form, gather all required documents and ensure the form is completed accurately. You can submit it via mail to the Bureau of the Fiscal Service, using their official mailing address. Alternatively, you may fax the form to the number provided by the Bureau or use their online submission portal if available. Remember to get the form notarized by a certifying officer before submission. Reviewing the Department of the Treasury's website for any updates or additional instructions is advisable.

This form was revised in November 2023. Ensure to check any specific submission deadlines or updates before completing the form.

The purpose of this form is to officially report and claim loss, theft, or destruction of United States registered securities. This form helps individuals reclaim their lost assets by providing detailed information about the missing securities. Properly completing this form ensures that your claim is processed efficiently by the Department of the Treasury.

• 1. Title of Security: Identify the security by providing the interest rate, title, call, and maturity dates.
• 2. Registration: Enter the exact inscription on each security.
• 3. Serial Number: Provide the serial number of each security.
• 4. Face Amount: Mention the face amount of each security.
• 5. Taxpayer Identifying Number: Enter your Social Security Number or Employer Identification Number.
• 6. Current Ownership: State if you are the current lawful owner of the securities.
• 7. Assignment/Endorsement Information: Provide details if the securities were assigned, endorsed, or transferred.
• 8. Loss Details: Indicate whether the securities were lost, stolen, or destroyed and provide relevant details.
• 9. Recovery Efforts: Describe any steps taken to recover the securities.
• 10. Legal Representation: Mention your legal capacity and court appointment details if applicable.
• 11. Minor Information: Provide details if a minor is named on the securities.
• 12. Petition Statement: Certified statement acknowledging the transfer of ownership to the United States and agreement to indemnify.
• 13. Signature: Sign the form in the presence of a certifying officer.

Failing to submit this form may result in the inability to recover your lost, stolen, or destroyed securities. Additionally, you may not receive any reimbursement or compensation for the loss.

• No Recovery of Securities: Your lost, stolen, or destroyed securities will not be recovered.
• No Reimbursement: You may not receive any reimbursement or compensation for the lost securities.
• Legal Consequences: Failure to report lost or stolen securities may have legal consequences.

• 1. Lost Securities: Report securities that have been lost.
• 2. Stolen Securities: Report securities that have been stolen.
• 3. Destroyed Securities: Report securities that have been destroyed.
• 4. Legal Representative: File on behalf of the owner if you are a legal representative.
• 5. Minors Named on Securities: Report if the securities are in the name of a minor.