Fs Form 4239 - 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

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For official use only:

Case No.

Customer Name

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

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