FS Form 5191                                                                                                 OMB No. 1530-0042
Department of the Treasury                        ®
Bureau of the Fiscal Service     Legacy Treasury Direct
(Revised June 2019)
                                                APPLICATION FOR RECOGNITION AS 
www.treasurydirect.gov                            NATURAL GUARDIAN OF A MINOR
844-284-2676 (toll free)
                                                                                 Visit us on the Web at www.treasurydirect.gov
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 under the laws of the United States.
             TYPE OR PRINT IN INK ONLY - APPLICATIONS WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS
 1.  Legacy Treasury Direct ACCOUNT INFORMATION                                                     FOR DEPARTMENT USE
ACCOUNT NUMBER(S):
                                                                                                    DOCUMENT AUTHORITY

                                                                                                             APPROVED BY

                                                                                                             DATE APPROVED

 2.  MINOR

NAME:

MINOR’S TAXPAYER IDENTIFICATION NUMBER:

DATE OF BIRTH:

 3.  GUARDIAN

NAME:

ADDRESS:
TELEPHONE:         (            )

RELATIONSHIP TO MINOR:           PARENT FURNISH CHIEF SUPPORT                    OTHER (specify)

MARRIED?  If your spouse did not apply as natural guardian with you, please have your spouse sign after the following statement:

I consent to the above-named parent acting as the guardian for our minor child.
                                                                                                    Signature
SEPARATED OR DIVORCED?  You must furnish a certified copy of court records showing you have custody of the minor.

NAMES AND ADDRESSES OF OTHERS WHO REGULARLY CONTRIBUTE TO THE MINOR’S SUPPORT, AND THE 
PERCENTAGE OF THEIR CONTRIBUTIONS:

DOES THE MINOR RESIDE WITH YOU?         YES     NO

IF NO, PROVIDE THE NAME AND ADDRESS OF THE PERSON WITH WHOM THE MINOR RESIDES:

                                 SEE INSTRUCTIONS FOR PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE

                                                                                                             RESET

 4.  AUTHORIZATION You must wait until you are in the presence of a certifying officer to sign this form.  
                   (If there are two owners joined by the word “and,” both must sign.)

I REQUEST THAT I BE RECOGNIZED AS NATURAL GUARDIAN OF THE SAID MINOR FOR PURPOSES OF FURNISHING THE 
PAYMENT INSTRUCTIONS FOR THE ACCOUNTS LISTED AND TO EXECUTE ANY NECESSARY TRANSACTION REQUESTS 
FOR THOSE ACCOUNTS.

I CERTIFY THAT NO LEGAL GUARDIAN OR SIMILAR REPRESENTATIVE HAS BEEN APPOINTED FOR THE SAID MINOR AND 
NO SUCH APPLICATION IS CONTEMPLATED AND THAT THE SAID MINOR HAS AN INTEREST IN WHOLE OR IN PART IN 
SECURITIES HELD IN THE ACCOUNTS LISTED.

IN CONSIDERATION FOR MY RECOGNITION AS NATURAL GUARDIAN OF THE MINOR, I HEREBY AGREE THAT I WILL 
PROMPTLY NOTIFY THE BUREAU OF THE FISCAL SERVICE IF (A) THE MINOR’S DISABILITY IS REMOVED UNDER THE 
LAWS OF THE STATE OF HIS OR HER RESIDENCE, (B) A LEGAL GUARDIAN OR SIMILAR REPRESENTATIVE IS APPOINTED 
FOR THE MINOR’S ESTATE, (C) I NO LONGER FURNISH CHIEF SUPPORT FOR THE MINOR (WHEN SUPPORT IS THE BASIS 
FOR RECOGNITION), OR (D) THE MINOR DIES.

                                                     SIGNATURE(S)

 5.  CERTIFICATION The natural guardian’s signature MUST be certified by an authorized certifying officer. 

  Instructions to Certifying Officer:
 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(IES) IS/ARE
                                           NAME(S) OF PERSON(S) WHO APPEARED
KNOWN OR PROVEN TO ME, PERSONALLY APPEARED BEFORE ME THIS                               DAY OF
                                                                                                           MONTH/YEAR
AT                                                                               AND SIGNED THIS APPLICATION.
                                          CITY/STATE

 ACCEPTABLE CERTIFICATIONS:                                SIGNATURE AND TITLE OF CERTIFYING OFFICER
 Financial Institution’s Official Seal or 
 Stamp (Such as Corporate Seal, Signature 
                                                                            NAME OF FINANCIAL INSTITUTION
 Guaranteed Stamp or Medallion Stamp). 
 Brokers must use a Medallion Stamp.
                                                                                 ADDRESS

                                                                                 CITY/STATE/ZIP CODE

                                                                                 TELEPHONE

                                                         2                                                 FS Form 5191

FS Form 5191
Department of the Treasury
Bureau of the Fiscal Service
(Revised June 2019)                                               INSTRUCTIONS FOR COMPLETING AN 
www.treasurydirect.gov                                            APPLICATION FOR RECOGNITION AS 
844-284-2676 (toll free)                                          NATURAL GUARDIAN OF A MINOR
PURPOSE
This form can be used to:
 •  apply for recognition as a natural guardian of a minor who owns, wholly or in part, Legacy Treasury Direct securities in an 
 estate where a legal representative has not been appointed.
 •  apply for recognition as a natural guardian when a designated natural guardian is no longer acting.  (A death certificate, 
 physician’s certificate, or certified evidence of court action must be submitted as proof of the designated natural guardian’s 
 inability to act.)

IMPORTANT NOTE
 • Only original signatures and forms will be accepted (stamped signatures are not acceptable).
 • Unless all the required information is provided legibly, there may be a delay in processing this form. To avoid delays, read 
 the instructions carefully and type or print clearly in ink only.
 • This form MUST be signed in all cases.
 • APPLICATIONS WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS.

WHO MAY APPLY
The parent with whom the minor resides may apply. If the minor resides with both parents, either or both may apply. The parent 
who has not joined in the application should consent by signing the statement within the box in Section 3. If the parents are 
separated or divorced, no consent is required provided that a certified copy of court records is furnished showing that the parent 
applying has custody. If the minor does not reside with either parent, the person who furnishes the minor’s chief support may apply.

No application will be considered if the Department of the Treasury is on notice that 1) the minor’s disability no 
longer exists under the laws of the state of his or her residence, 2) a legal guardian or similar representative of the 
minor’s estate had been appointed, 3) the applicant is not entitled to act as natural guardian, or 4) the minor has died.

 1.  Legacy Treasury Direct ACCOUNT INFORMATION

Provide the ACCOUNT NUMBER(S) of all Legacy Treasury Direct accounts owned wholly or in part by the minor.

 2.  MINOR  

Provide the minor’s NAME, TAXPAYER IDENTIFICATION NUMBER, and DATE OF BIRTH.

 3.  GUARDIAN  

Provide your NAME and ADDRESS, and indicate your relationship to the minor. Remember: If you are married and your spouse 
did not apply as natural guardian with you, please have your spouse sign the statement within the box. If you’re separated
or divorced, furnish a certified copy of court records showing you have custody of the minor.

If you are applying as the furnisher of chief support for the minor, provide the names and addresses of others who regularly 
contribute to the minor’s support and the extent of their contributions (expressed as a percentage of the minor’s total support).

Indicate whether the minor resides with you.  If not, provide the name and addresses of the person with whom the minor resides.

 4. AUTHORIZATION 

Read the authorization statement carefully.  In the presence of an authorized certifying officer, sign the form in ink.

 5. CERTIFICATION 

Certification of your signature is required.  Acceptable certifying officers include authorized employees of insured depository institutions 
and corporate central credit unions. Certification date, address, and telephone number of the financial institution are required.

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WHERE TO SEND
Completed forms must be submitted to:
             Treasury Retail Securities Site 
             PO Box 9150 
             Minneapolis, MN 55480-9150
This form should be submitted in support of a specific transaction request.  Subsequent requests should be accompanied by 
additional natural guardian applications forms.

Contact
Call us toll-free in the United States at 844-284-2676. Outside the U.S.? Call us at +1-304-480-6464.

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 
Fiscal Service 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 
Fiscal Service; 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 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 
completed form to this address; instead, submit completed form to the address shown in “WHERE TO SEND” in the 
Instructions.

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