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For official use only:

Customer Name Case No.

FS Form 4239 (Revised March 2016) OMB No. 1530-0024

Request by Owner or Person Entitled to Payment or Reissue

of United States Savings Bonds/Notes Deposited in Safekeeping
When Original Custody Receipts Are Not Available

IMPORTANT: Follow instructions in filling out this form. You should be aware that the making of any false, fictitious, or fraudulent claim or statement
to the United States is a crime that is punishable by fine and/or imprisonment.
PRINT IN INK OR TYPE ALL INFORMATION

NOTE: For Series EE and Series I savings bonds, we no longer issue substitute bonds in paper form. We issue those
substitute bonds in electronic form, in our online system TreasuryDirect. For information on opening an account in
TreasuryDirect, go to www.treasurydirect.gov.
1. I , ,
(Name) (Social Security Number)

certify that United States Savings Bonds, numbers

,
Office of the Treasurer of the United States,
were held in safekeeping at:
Federal Reserve Bank of
and that I am the person lawfully entitled to claim the bonds as:
owner
coowner
beneficiary
legal representative of
person entitled to the estate of
other (explain)

and that the original custody receipts were mislaid, lost, or stolen and, after a diligent search, have not been found.
I agree to return the original receipts to the Bureau of the Fiscal Service for cancellation if they are ever located.
2.
I request substitute bonds in electronic form in my TreasuryDirect account
TreasuryDirect account number: Social Security Number:
Account name:
I request payment, by direct deposit, of the current redemption value

Name(s) on Bank Account Depositors Account No.

Type of account: Checking Savings Bank Routing No.:

Financial Institutions Name Phone No.

3. Signatures - You must wait until you are in the presence of a certifying officer to sign this form. (See the certification
sections on the next page.)

(Signature) (E-mail Address) (Daytime Telephone No.)

(Signature) (E-mail Address) (Daytime Telephone No.)

FS Form 4239 Department of the Treasury | Bureau of the Fiscal Service 1

4. Certification.

Instructions to Certifying Individual:

1. Name of person(s) who appeared and date of appearance MUST be completed.
2. Medallion stamps require an original signature.
3. Person(s) must sign in your presence.

I CERTIFY that , whose identity is known or was

(Name of Person Who Appeared)

proven to me, personally appeared before me this day of ,

(Month / Year)

at , and signed this form.

(City / State)

(Signature and Title of Certifying Individual)

(OFFICIAL STAMP
OR SEAL) (Name of Financial Institution)

(Address)
ACCEPTABLE CERTIFICATIONS: Financial
institution's official seal or stamp (such as corporate
seal, signature guaranteed stamp, or medallion stamp).
Brokers must use a medallion stamp. (City / State / ZIP Code)

(Notary certification is NOT acceptable.) (Telephone)

I CERTIFY that , whose identity is known or was

(Name of Person Who Appeared)

proven to me, personally appeared before me this day of ,

(Month / Year)

at , and signed this form.

(City / State)

(Signature and Title of Certifying Officer)

(OFFICIAL STAMP
OR SEAL) (Name of Financial Institution)

(Address)
ACCEPTABLE CERTIFICATIONS: Financial
institution's official seal or stamp (such as corporate
seal, signature guaranteed stamp, or medallion stamp).
Brokers must use a medallion stamp. (City / State / ZIP Code)

(Notary certification is NOT acceptable.) (Telephone)

FS Form 4239 Department of the Treasury | Bureau of the Fiscal Service 2

 INSTRUCTIONS
USE OF FORM When original safekeeping custody receipts are not available, use this form to request payment or reissue of
United States Savings Bonds/Notes deposited for safekeeping with the Office of the Treasurer of the United States or a Federal
Reserve Bank. (If safekeeping receipts are available, they must be submitted to the address shown on this form.)

WHO MAY COMPLETE THE FORM The form must be completed by the owner, coowner, surviving beneficiary, legal
representative of the estate of a deceased or incompetent owner, or the person entitled to the estate of a deceased owner. If the
original bonds are registered in coownership form, both coowners must sign. If a coowner is deceased, see EVIDENCE below.

EVIDENCE The following evidence is required to support the request:

Request by: Evidence Required
1. Surviving coowner or A copy of the deceased registrant's death certificate, certified or sworn to by the State or local
beneficiary registrar, under seal, to be a true and correct copy taken from the official records.
A court certificate or a certified copy of the representative's letters of appointment, under seal
2. Legal representative of
of the court, showing that the appointment is still in full force and effect. If there is no legal
the estate of a deceased
representative in the case of a deceased or incompetent owner or the decedent's estate has
or incompetent owner
been fully administered and closed, the Bureau of the Fiscal Service must be so informed and
COMPLETION OF FORM
ITEM 1. Check the appropriate boxes to indicate where the bonds were held and your entitlement to them. List the bonds by
serial number.
ITEM 2. Mark the appropriate box to indicate whether payment or reissue is desired. If requesting payment, provide direct-
deposit information. If a registrant is deceased, see EVIDENCE above. If a security has matured or will reach
maturity before a reissue can be processed, payment will be issued. All Savings Bonds of Series A, B, C, D, E, F,
G, H, J, and K, and all Savings Notes, have reached final maturity and can only be redeemed. NOTE: You
may add a secondary owner or beneficiary once bonds have been replaced in electronic form in your TreasuryDirect
account. For instructions on adding a secondary owner or beneficiary, access your account and click how do I at
the top of the page.
ITEM 3. Sign the form and provide your daytime telephone number. The signature of a registered owner should be in the
same form as that appearing on the bonds. The signature of a representative or fiduciary must be in the same form
as that shown in the court papers or other evidence of authority and must be followed by the proper title and
reference to the estate, as for example, "John W. Smith, administrator of the estate of Henry L. Smith, deceased."
ITEM 4. Each person whose signature is required must appear before and establish identification to the satisfaction of an
authorized certifying officer and sign the form in the officers presence. The certifying officer must complete the
certification forms provided and impress the seal or stamp used when certifying requests for payment. Authorized
officers are available at banking institutions, including credit unions, in the United States. For a complete list of such
officers, see Department of the Treasury Circulars No. 530, current revision, and Public Debt Series No. 3-80.
WHERE TO SEND Send this form and evidence, if any, to the Treasury Retail Securities Site, P.O. Box 214, Minneapolis, MN
55480-0214.

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; or 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 a completed form to this
address; send to the address shown in "WHERE TO SEND."
FS Form 4239 Department of the Treasury | Bureau of the Fiscal Service 3