Form 1000                                                   Ownership Certificate 
(Rev. September 2016)                                                                                                                            OMB No. 1545-0054 
Department of the Treasury                                                              
Internal Revenue Service          ▶ Information about Form 1000 is at www.irs.gov/uac/about-form-1000.
To be used by a  U.S. citizen, resident individual, fiduciary, partnership, or nonresident partnership all of whose members are citizens or residents, in connection with 
interest on bonds of a corporation containing a tax-free covenant and issued before January 1, 1934. 
Owner of bonds                                              U.S. identifying number       Name of withholding agent              Employer identification number

Address of owner (number and street, city or town, state or province, country, ZIP or     U.S. address of withholding agent (number and street, city or town, state, and 
foreign postal code)                                                                      ZIP code) 

I CERTIFY that to the best of my knowledge and belief, the          Name of bond and date of issue                             Date interest due Date interest paid 
information entered on this form is correct. 
Signature of owner, fiduciary, trustee, or agent 
Address of fiduciary, trustee, or agent (number and street, city or            Classes of Bond Owners                          Gross Amount        Tax  
                                                                                                                               of Interest Paid    Assumed  
town, state or province, ZIP or foreign postal code)                                                                                               (2%) 
                                                                    1 (a) Individual, estate, or trust, whose taxable income 
                                                                      exceeds  the  deductions  for  exemptions;  or  (b) 
                                                                      partnership  .    . .    . .    . . . .       . .        $                 $ 
If an estate or trust, enter name                                                                                                                  No tax paid 
                                                                    2 Individual,  estate,  or  trust,  whose  taxable  income                     by corporation 
                                                                      does not exceed the deduction for exemptions .  .        $ 
For Paperwork Reduction Act Notice, see instructions.                          Cat. No. 17097D                                   Form 1000 (Rev. 9-2016) 

Form 1000 (Rev. 9-2016)                                                                                                         Page  2 
Instructions for Owner, Fiduciary, Trustee, or                       States. You are required to give us the information. We need it to 
                                                                     ensure that you are complying with these laws and to allow us to 
Agent                                                                figure and collect the right amount of tax. 
Use a separate Form 1000 for each issue of bonds. If amended         You are not required to provide the information requested on a  
certificates are necessary, forward them to the withholding agent by form that is subject to the Paperwork Reduction Act unless the form 
February 1 of the following year.                                    displays a valid OMB control number. Books or records relating to a 
Where to file.File this form with the withholding agent for interest form or its instructions must be retained as long as their contents 
payments on bonds that have a tax-free covenant and that were        may become material in the administration of any Internal Revenue 
issued before 1934 by a domestic corporation or a resident or        law. Generally, tax returns and return information are confidential, 
nonresident foreign corporation.                                     as required by Internal Revenue Code section 6103. 
                                                                     The time needed to complete and file this form will vary  
Instructions for Withholding Agents                                  depending on individual circumstances. The estimated average  
                                                                     time is: Recordkeeping, 3 hr., 6 min.; Learning about the law or 
Use Form 1042 to summarize Forms 1000. Do not send Form 1000         the form, 6 min.; Preparing the form, 9 min. 
to the IRS. Keep Form 1000 for at least 4 years after the end of the If you have comments concerning the accuracy of this time  
last calendar year in which the income the form applies to is paid.  estimate or suggestions for making this form simpler, we would be 
If a nonresident foreign corporation with a fiscal or paying agent   happy to hear from you. You can send us comments from 
in the United States issues the obligation, modify Form 1000 to      www.irs.gov/formspubs. Click on “More Information” and then on 
show the name and address of the nonresident debtor corporation      “Give us feedback.” You can write to the Internal Revenue Service, 
in addition to the name and address of the U.S. fiscal or paying     Tax Forms and Publications, 1111 Constitution Ave. NW, IR-6526, 
agent.                                                               Washington, DC 20224. Do not send this form to this address. 
                                                                     Instead, see Where to file, earlier. 
Paperwork Reduction Act Notice. We ask for the information on 
this form to carry out the Internal Revenue laws of the United