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       For official use only:                                                                    
       Customer Name                                                                            Case Number             
       FS Form 1050  (Revised June 2022)                                                                                      OMB No. 1530-0027 

       Creditor’s Request for Payment of Treasury 

       Securities Belonging to a Decedent’s Estate 

       Being Settled Without Administration                                                                                                 
                                                                                                                                                 
      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 
 An unpaid creditor must complete this form to request payment of United States Securities and/or related payments belonging to a 
 decedent’s estate that is not being administered.  See the instructions for additional information.        
                                          Carefully read the instructions before completing this form. 
      PART A – ESTATE INFORMATION 
      Provide the information below and submit certified copies of the death certificates for all deceased registrants. 

                     (Name of Deceased Owner - If more than one person named on the securities, the person who died last)                  

                     (Decedent’s Social Security Number)                        (Jurisdiction of Legal Residence)             
      By signing this form, I certify that I have read the instructions for the use of this form and I am entitled to make this claim.  
       
      If the  above statement does not  apply, do not complete this  form.   Instead,  send the securities  and all  evidence  and/or 
      documentation concerning the estate to the address shown in “WHERE TO SEND.” 
 PART B – PAYMENT TO CREDITOR 
Provide the information below and submit any supporting documentation (e.g. receipts, statements, invoices). 

1. Amount Owed:  $____________  2. Nature of Claim:  _______________________________________________________________ 

3. I hereby certify that the amount owed has not been paid and is still justly due and owing to the below-named creditor.  I further certify 
that the debt has not been barred by any applicable law.  I request payment of United States Treasury securities and/or related payments 
belonging to the decedent, to the extent entitled. 

Pay to:                                                                                                                                   
                                          (Name)                                                            (Phone Number)                  
                                                                                                                                            
                               (Mailing Address)                                                            (E-mail Address)                
                                                   
4. Description of securities and/or related payments:          
       TITLE OF SECURITY       ISSUE      FACE AMOUNT           IDENTIFYING NUMBER                           REGISTRATION 
                               DATE 
                                                                                                           
 FS Form 1050                             Department of the Treasury | Bureau of the Fiscal Service                                        1

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 PART C - SIGNATURE AND      CERTIFICATION 
 I certify under penalty of perjury that the information provided herein is true and correct to the best of my knowledge and belief.  The 
 United States is not liable to any person for the improper payment of securities.  I bind myself, my 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.  I 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 payments.       
                                                                     
                   You must wait until you are in the presence of a certifying officer to sign this form. 
(SEAL)* 
                                                                                                                                
                                                      (Signature of individual creditor or name of organizational creditor)     

                                                 By                                                                            
* There is no seal                                                (Signature and title of officer of organizational creditor)   
                                                                     
Instructions to Certifying Officer:  1.  Name of the 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(ies) is/are known or  
                                  (Name[s] of Person[s] 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)                                  
                                                                                                                                                     
ACCEPTABLE CERTIFICATIONS:                                                           (Address)                                                       
                                                                                                                                                     
Financial Institution's Official Seal or Stamp 
(such as Corporate Seal, Signature Guaranteed                                       (City/State/ZIP Code)                                            
Stamp, or Medallion Stamp).                                                                                                                          
 
(Notary certification is NOT acceptable.)                                            (Telephone)                                                     
                                                                    
                                   PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE 
  
 The collection of the information you are requested to provide on this form is authorized by 31 U.S.C. CH. 31 relating to the public debt of the United 
 States.  The furnishing of a Social Security Number, if requested, is also required by Section 6109 of the Internal Revenue Code (26 U.S.C. 6109). 
  
 The purpose of requesting the information is to enable the Bureau of the 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 06 minutes to complete this form.  However, you are not required to provide information requested unless a valid 
 OMB control number is displayed on the form.  Any comments or suggestions regarding this form should be sent to the Bureau of the Fiscal Service, 
 Forms Management Officer, Parkersburg, WV 26106-1328.  DO NOT SEND completed form to this address; send to the address shown in “Where To 
 Send” in the Instructions. 
  
 FS Form 1050                      Department of the Treasury | Bureau of the Fiscal Service                                                         2

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INSTRUCTIONS

USE OF FORM – An unpaid creditor must complete this form to request payment of United States Securities and/or related
payments belonging to a decedent’s estate unless:
• A legal representative has been or will be appointed through the court.
• The estate will be settled in accordance with the law of the decedent’s domicile (such as Summary Administration,
Small Estates Act, Texas Muniment of Title, Louisiana Judgment of Possession, etc.).
• The debt has been barred by any applicable law.
• The total of all securities and/or related payments owned by the decedent as of the date of death exceeds
$100,000 redemption and/or par value.
• There is an individual entitled to the estate according to the law of the decedent’s domicile.

If any of these circumstances apply, do not complete this form. Instead, send the securities and all evidence and/or
documentation concerning the estate to the address shown in “WHERE TO SEND” on the last page of these instructions.
Upon review of the submission, we will provide additional instructions, if necessary.

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.

PART A – ESTATE INFORMATION
Provide the requested information regarding the decedent. If more than one deceased person is named on the securities,
provide the information for the person who died last. Submit certified copies of the death certificates for all deceased
registrants.
Insert the following information:
• Decedent’s name
• Decedent’s Social Security Number
• Jurisdiction (state, district, or territory) of decedent’s last legal residence
Note: The decedent’s Social Security Number will be used to report the interest earned to the Internal Revenue Service for
Federal income tax purposes.

PART B – PAYMENT TO CREDITOR
Provide the information below and submit any supporting documentation (e.g. receipts, statements, invoices).
Payment will be limited to the amount of the debt as shown in the documentation submitted and will not exceed
the value of the securities. (Reissue is not permitted.)

1. Provide the amount owed.

2. Provide the nature of the claim (how the debt was incurred).

3. Provide the creditor’s name, phone number, mailing address, and, if he or she has one, e-mail address.

4. Describe the securities and/or checks:
• TITLE OF SECURITY – Identify each security by series, interest rate, type, CUSIP, and 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.

FS Form 1050 Department of the Treasury | Bureau of the Fiscal Service 3

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PART B – PAYMENT TO CREDITOR (Continued) 
EXAMPLES: 
     TITLE OF SECURITY              ISSUE     FACE AMOUNT       IDENTIFYING NUMBER                                 REGISTRATION 
                                    DATE 
   Paper Marketable Security                                   Serial # 
   9 1/8 % TREASURY BOND OF                                    123                    JOHN DOE AND JANE DOE 
   2004-2009 MATURES 5/15/09        5/15/79         $5,000                            SSN 222-22-2222 
   CUSIP 912810CG1 
                                                                                      ACCT # 4800-123-1234 
   Electronic Marketable Security                                                     JOHN DOE  
   CUSIP 912795QW4                  2/5/04          $1,000                            SSN 222-22-2222 
                                                                                       
   Electronic Series I Savings Bond                            Confirmation #         ACCT # N-111-11-1111 
   SERIES I                         1/1/02          $100       IAAAB                  JOHN DOE 

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

If unsure what to provide in each of the areas, furnish all identifying information in the space for REGISTRATION. 
  
PART C – SIGNATURES AND CERTIFICATIONS 
SIGNATURES   – The application must be signed in ink. 
 
  If the creditor is an…          The form must be signed by…           And the following must be provided… 
  Individual                      The individual                        N/A 
  Organization                    A person authorized to  sign on  Evidence of the signer’s authority, his or her title, and the 
                                  behalf of the organization            name and seal of the organization 
  Partnership                     A general partner                     Signer’s title and the name and seal of the partnership 
  Corporation                     An authorized officer of the          Evidence of the signer’s authority, his or her title, and the 
                                  corporation                           name and seal of the corporation 
Note:  If the organization, partnership, or corporation has no seal, mark the box provided. 
 
Where evidence of your authority is required, please provide a resolution or other similar documentation. 
 
CERTIFICATION – You must appear before and establish identification to the satisfaction of an authorized certifying officer.  
The form must be signed in the officer’s presence.  The certifying officer must affix the seal or stamp that is used when 
certifying requests for payment.  Authorized certifying officers are available at most financial institutions, including credit 
unions.  
 
ADDITIONAL REQUIREMENTS – 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 and/or the formal administration of the estate. 
 
WHERE TO SEND – Unless otherwise instructed in accompanying correspondence, send this form, all securities and/or related checks, 
and any necessary evidence to the address below.  (Don’t send Instructions pages.) 
 
               Treasury Retail Securities Services 
               PO Box 9150 
               Minneapolis, MN 55480-9150 
                
Note: You must use only one form and describe all of the securities. 
   
  FS Form 1050                      Department of the Treasury | Bureau of the Fiscal Service                                   4

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