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I CERTIFY that _________________________________________________________________________ , whose identity(ies)
(Names of Persons Who Appeared)
is/are known or proven to me, personally appeared before me this _______________ day of _______________ __________
(Month) (Year)
at ___________________________________________________ and signed this form.
(City, State)
________________________________________________________
(Signature and Title of Notary or Certifying Officer)
________________________________________________________
(Name of Financial Institution)
________________________________________________________
(Address)
________________________________________________________
(City, State, ZIP code)
________________________________________________________ SEE INSTRUCTIONS FOR ACCEPTABLE CERTIFICATION
(Telephone)
INSTRUCTIONS
IF YOU LIVE IN A DECLARED DISASTER AREA: You need to complete only parts 1, 5, 6B, and 7. Write the word “DISASTER” on
the top of the first page of the form and on the front of the envelope.
PURPOSE OF FORM – Use this form to apply for relief on account of the loss, theft, or destruction of United States Savings Bonds.
"Bonds," as used on this form, refers to Savings Bonds, Savings Notes, Retirement Plan Bonds, or Individual Retirement Bonds.
WHO MAY APPLY – This form must be completed and signed by all persons named on the bonds, or by an authorized representative.
PROOF OF DEATH – If a registrant is deceased, you must submit a certified copy of his or her official death certificate with this form.
LEGAL REPRESENTATIVE – If you were appointed as legal representative because:
• the owner is deceased (with no surviving coowner or beneficiary named on the bonds), or
• the owner or coowner is a minor, or
• the owner or coowner is incapacitated,
complete the form and submit a court certificate or certified copy of your letters of appointment, under court seal and dated within one year
of submission, showing the appointment is still in full force. If your name and official capacity are shown in the registration of the bonds,
evidence of your appointment is not necessary.
If no legal representative has been appointed for a deceased or incompetent owner, advise the Bureau of the Fiscal Service and additional
instructions will be provided.
AMOUNT OF BONDS EXCEEDS $5,000 – If the amount of the bonds involved exceeds $5,000 and an investigation was made by a law
enforcement agency or an insurance, transportation, or similar business organization, provide a copy of the report.
COMPLETION OF FORM – Print clearly in ink or type all information requested.
ITEM 1.
• Describe the missing bonds by bond serial number, or
• If you don’t know serial numbers:
o Treasury Hunt search--If bonds were issued in 1974 or later, go to TreasuryHunt.gov, click the “Search Treasury Hunt”
button, and follow instructions for a unique FS Form 1048 showing a Treasury Hunt reference number. Complete item
1 to the best of your ability.
o If bonds were issued before 1974, state on this form the exact issue date or a range of dates, and the Social Security
Number, name (including middle name or initial), and complete address (street, city, state) that appear on the bonds.
In all scenarios above: State the total number of missing bonds. If you need more space to list bonds, attach either a “Continuation
Sheet for Listing Securities” (FS Form 3500), available at http://www.treasurydirect.gov/forms/sav3500.pdf, or a plain sheet of paper.
ITEM 2. Mark the appropriate boxes and provide complete details of the loss, theft, or destruction.
ITEM 3. Provide details regarding your authority to complete a claim for the missing bonds. If you have been court-appointed, see
"LEGAL REPRESENTATIVE" above.
FS Form 1048 Department of the Treasury | Bureau of the Fiscal Service 5
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