FS Form 5188
FS Form 5188
FS Form 5188
1. APPOINTMENT
________________________________________________________ as my attorney-in-fact.
(Name of Attorney-in-Fact)
2. AUTHORITY
A. Relating to my Treasury securities and United States Savings Bonds and Notes, I authorize
my attorney-in-fact named above to perform any and all transactions that Treasury regulations
permit an attorney-in-fact to make. This authority includes the right to execute tax documents
related to these securities. This does not include the authority to make transfers to the
attorney-in-fact or to make gifts to others.
B. I authorize my attorney-in-fact named above to exercise any powers and duties, whether or
not discretionary, that I am authorized to perform regarding securities belonging to any trust,
probate estate, guardianship, conservatorship, custodianship, or other similar estate for which
I am now, or may later be, appointed as fiduciary.
C. In addition to one or both of the above, I authorize my attorney-in-fact to make gifts to others.
I further authorize my attorney-in-fact to make transfers (either for consideration or as a gift) to
the attorney-in-fact.
Authorized transactions may include, but are not limited to, changes of payment information, collection
of interest, redemptions, transfers, assignments, purchases by ACH or any other authorized payment method,
or reinvestments. The Bureau of the Fiscal Service will not be liable for any loss, cost, or expense that you
may incur as a result of transactions made by the attorney-in-fact appointed.
_____________________________________________________ ______________________________________________
(Print Name) (Social Security Number)
_____________________________________________________ ______________________________________________
(City) (State) (ZIP Code) (E-mail Address)
Instructions to Certifying Officer: 1. Name of the person(s) who appeared and date of appearance MUST be completed.
2. If a Medallion stamp is used, an original signature is required. 3. Person(s) must sign in your presence.
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 Certifying Officer)
________________________________________________________
(Name of Financial Institution)
________________________________________________________
(Address)
________________________________________________________
(City, State, ZIP code)
________________________________________________________
(Telephone)
INSTRUCTIONS
USE OF FORM – Use this form to appoint and authorize an attorney-in-fact to conduct any and all authorized
transactions regarding Treasury securities. These securities include, but are not necessarily limited to, Treasury bills,
notes, bonds, and TIPS, FRNs, and all series of United States Savings Bonds and Savings Notes. Authorized
transactions include, but are not limited to, changes of payment information, collection of interest, redemptions,
transfers, assignments, purchases by ACH or any other authorized payment method, reinvestments, and/or the
completion of tax documents. (An attorney-in-fact may not reissue definitive savings bonds.)
IMPORTANT NOTICES
• This form gives the individual or organization you name as attorney-in-fact broad powers to handle your securities
and/or securities for which you are acting on the owner's or entitled party's behalf as fiduciary. If you have
questions about these powers, you should seek professional legal advice before signing this form.
• The attorney-in-fact is not permitted to transfer securities to an account in his or her own name unless the grantor
marks Box C.
• Checking Box C in "2. AUTHORITY" will authorize the attorney-in-fact to make transfers of your Treasury
securities without limitations.
• If the grantor is an organization, submit a resolution authorizing the appointment of an attorney-in-fact.
FS Form 1010 (available at www.treasurydirect.gov) may be used for this purpose.
• If the grantor of the power of attorney is a trustee, provide the following excerpts of the trust instrument:
o a copy of the page showing the name and date of the trust
o a copy of the page showing the trustee's authority to appoint an agent or attorney-in-fact
o a copy of the signature page
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 the completed form to
this address; send it to the correct address shown in "WHERE TO SEND.”
FS Form 5188 Department of the Treasury | Bureau of the Fiscal Service 3