U.S. Treasury Account Authorization Form
U.S. Treasury Account Authorization Form
U.S. Treasury Account Authorization Form
TreasuryDirect
OMB #1535-0138
Account Authorization
www.treasurydirect.gov
IMPORTANT: Follow instructions in lling out this form. You should be aware that the making of any false, ctitious, or fraudulent claim or statement to the United States is a crime that is punishable by ne and/or imprisonment. PRINT IN INK OR TYPE ALL INFORMATION
Instructions
1. Wait until you are in the presence of a certifying ofcer to sign this form. Identication may be required. 2. Acceptable certifying ofcers include authorized employees of insured depository institutions and corporate central credit unions. Certication by a notary public is NOT acceptable. 3. Mail the completed authorization form to Department of the Treasury, Bureau of the Public Debt, P.O. Box 7015, Parkersburg, WV 26106-7015.
Authorization
I submit this account authorization pursuant to the provisions of 31 CFR Part 363. I understand that my TreasuryDirect account will be activated upon receipt and approval of this authorization. Under penalty of perjury, I certify the information provided is true, correct and complete.
(Signature) Taxpayer Identication Number (SSN/EIN)
Mailing Address
Telephone (Daytime)
E-mail Address
Certifying Ofcer:
I CERTIFY that
The individual must sign in your presence and you must complete the certication and afx your stamp or seal. Acceptable certications include the nancial institutions ofcial seal or stamp (such as corporate seal, signature guaranteed stamp, or medallion stamp). Certication by a notary public is NOT acceptable.
day of
(Month)
,
(Year)
at
(City) (State)
(Address)
ACCEPTABLE CERTIFICATIONS: Financial institutions ofcial seal or stamp (such as corporate seal, signature guaranteed stamp, or medallion stamp). (Notary certication is NOT acceptable.)
(Phone Number)