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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, 6.B. 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. If you don't know the bond serial numbers, you must provide 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. Also state the total number of missing bonds. If you need more space, 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.
ITEM 4. A minor (who does not have a court-appointed guardian) who is requesting payment or who is named on Series HH bonds may
complete and sign the form on his or her own behalf if, in the opinion of the notary or certifying officer, he or she is of sufficient
competency and understanding to comprehend the nature of the transaction. The parents or parent with whom the minor resides must
complete this item if a minor is named on the bonds and he or she is not of sufficient competency and understanding to complete the form
on his or her own behalf, or is requesting electronic substitute bonds for Series EE or Series I. Provide the minor’s name, date of birth,
Social Security Number, and all other requested information. If the minor does not reside with either parent, the form must be completed
and signed by the individual who furnishes the minor’s chief support.
FS Form 1048 Department of the Treasury | Bureau of the Fiscal Service 5
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