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• TAXPAYER IDENTIFICATION NUMBER CORRECTION – Mark this box to correct the Taxpayer Identification Number that currently
appears on your account. Provide the correct number for the first-named owner.
Item 3. SIGNATURES AND CERTIFICATION
SIGNATURES –This form must be signed in all cases. The owner named on the Legacy Treasury Directaccount, his or her authorized
representative, or the person entitled to the account must sign the form in ink, and provide his or her title (if applicable), mailing address,
daytime telephone number, and, if applicable, e-mail address. If there are two owners joined by the word "and," both must sign this
form if it involves a name change (other than a minor change), payment information change, or consolidation of accounts. If a
correction of the Taxpayer Identification Number is requested, the form must be signed by the first-named owner whose
Taxpayer Identification Number is shown.
Certification of the signature is required if you add or delete a beneficiary or second owner, if you change the payment information, if you
change your name (other than a minor change) and don't submit supporting evidence, if you change your registration from an individual
account to your grantor trust, or if you change your registration from a grantor trust to an individual account. You must wait until you are
in the presence of a certifying individual to sign this form.
If the account is registered in the name of an organization or corporation, a current Resolution for Transactions Involving Treasury
Securities (FS Form 1010) or your own corporate resolution must be submitted with this request. (For FS Form 1010, go to
www.treasurydirect.gov.)
Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association, created or organized in the United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• A domestic trust.
CERTIFICATION – If certification is applicable, each person whose certified signature is required must appear before and establish
identification to the satisfaction of an authorized certifying individual and sign and date the form in the individual’s presence. The
certifying individual must fully complete the certification blocks provided and affix the seal or stamp which is used when certifying requests
for payment. Acceptable certifications include a Financial Institution’s Official Seal or Stamp (such as Corporate Seal, Signature
Guaranteed Stamp, or Medallion Stamp). Brokers must use a Medallion Stamp (original signature is required). Authorized certifying
individuals include authorized employees of insured depository institutions and corporate central credit unions.
Please note that certification by a notary public is NOT acceptable.
WHERE TO SEND – Send the completed form to: Treasury Retail Securities Services, P.O. Box 9150, Minneapolis, MN 55480-9150.
Call us toll-free in the United States at 844-284-2676. Outside the U.S.? Call us at +1-304-480-6464. Legal evidence or documentation
you submit cannot be returned.
To ensure timely processing, this form must be received at least ten business days in advance of:
• the maturity date of the security, and
• an interest payment date for the security.
CONFIRMATION OF TRANSACTION(S) – You will receive a Legacy Treasury Direct Confirmation of Change in Investor Account
Information after your transaction has been processed. A Statement of Account will be sent for each account when Legacy Treasury
Direct accounts are consolidated.
NOTICE UNDER 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 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 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; send to the address shown in "WHERE TO SEND" in the Instructions.
FS Form 5178 Department of the Treasury | Bureau of the Fiscal Service 4
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