RESET PD F 5182 E OMB NO. 1535-0069 Department of the Treasury Bureau of the Public Debt (Revised September 2009) NEW ACCOUNT REQUEST 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, 1-800-722-2678 fictitious, or fraudulent claim or statement to the United States is a crime under the laws of the United States. SEE INSTRUCTIONS – TYPE OR PRINT IN INK ONLY – NO ALTERATIONS OR CORRECTIONS 1. Legacy Treasury Direct ACCOUNT INFORMATION FOR DEPARTMENT USE ACCOUNT NAME DOCUMENT AUTHORITY APPROVED BY ADDRESS DATE APPROVED EXT REG FOREIGN BACKUP City State ZIP Code REVIEW 2. TAXPAYER IDENTIFICATION NUMBER CLASS 1st Named Owner OR Social Security Number Employer Identification Number 3. TELEPHONE NUMBERS Work Home 4. PAYMENT INFORMATION ROUTING NUMBER FINANCIAL INSTITUTION (Limited to 30 characters/spaces) NAME ON ACCOUNT (Limited to 22 characters/spaces) Checking Savings ACCOUNT NUMBER (Check One) 5. AUTHORIZATION I submit this request pursuant to the provisions of Department of the Treasury Circulars, Public Debt Series Nos. 2-86 (31 CFR Part 357) and 1-93 (31 CFR Part 356). Under penalties of perjury, I certify that: 1. The number shown on this form is my correct T axpayer I dentification N umber (or I am waiting for a number to be issued to me),and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a United States citizen (including a United States resident alien). Instructions. You must cross out I tem 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. I further certify that all other information provided on this form is true, correct, and complete. Signature Date SEE INSTRUCTIONS FOR PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE. |
PD F 5182 E INSTRUCTIONS FOR COMPLETING Department of the Treasury Bureau of the Public Debt A NEW ACCOUNT REQUEST (Revised September 2009) Visit us on the web at www.treasurydirect.gov 1-800-722-2678 PURPOSE You may use this form to establish a Legacy Treasury Direct account WITHOUT PURCHASING SECURITIES. The Department of the Treasury will establish and maintain your book-entry account for the future deposit of securities. This form cannot be used for the purchase of securities or to request a change to an existing account. IMPORTANT NOTICES • If you are submitting a tender, you do NOT need to complete this form. A Legacy Treasury Direct account will be established on the basis of the information you provide on the tender. • To avoid delays, read the instructions carefully and either type your answers or print them clearly, using ink. • REQUESTS WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS. • This form must be signed. Only original signatures and forms will be accepted (stamped signatures are not acceptable). 1. Legacy Treasury Direct ACCOUNT INFORMATION ACCOUNT NAME Enter the name(s) of the owner(s) for whom the Legacy Treasury Direct account will be established. Accounts may be established in the names of one or two individuals, an estate, a trust, corporation, association, natural guardian, etc. (NOTE: A minor may not register an account or purchase securities in his or her name alone.) See the table of common registrations on the last page of these instructions. Because registrations establish clear ownership and survivorship rights, we recommend that you consult your Treasury Retail Securities Site when you have questions about the proper wording. ADDRESS Provide a complete address, including ZIP Code. All mailings (including notices, statements, confirmations, checks [where permitted], and tax reporting documents) will be sent to this address. 2. TAXPAYER IDENTIFICATION NUMBER Provide the T axpayer dentification I Number required on tax returns and other documents submitted to the Internal Revenue Service (IRS). For individuals, this is the S ocial ecurity S umberN(SSN) of the person whose name appears FIRST on the account. The SSN of a minor or incompetent is required for accounts established in a fiduciary capacity for these individuals. In the case of a partnership, company, organization or trust, use the E mployer dentification I N umber (EIN) assigned by the IRS. (If you are not a United States citizen, please attach IRS Form W-8 BEN or W-8 ECI.) To use Electronic Services for Treasury Bills, Notes, and Bonds, you must have a Legacy Treasury Direct account and a Taxpayer I dentification N umber. If you’re not a United States citizen and want to use our electronic services, you need an ndividualI Taxpayer I dentification Number (ITIN). To apply for an ITIN or just obtain more information, visit the Internal Revenue’s web page at www.irs.gov or call (215) 516-4846. 3. TELEPHONE NUMBERS Please provide the telephone numbers (including area codes) where you may be contacted if there are questions about this request or your account. 4. PAYMENT INFORMATION Try using Pay Direct®—a secure way Enter the following information: to buy securities without checks. • ROUTING NUMBER (your financial institution’s ABA identifying number) It’s easy! Just ask your financial institution • FINANCIAL INSTITUTION (the name of the institution to which payments are to be made) to verify if your account can accept debit transactions. We’ll withdraw the exact • NAME ON ACCOUNT (the name as it appears on the account at your financial institution) amount from your bank account to pay • ACCOUNT NUMBER (the account number at your financial institution) for whatever security you’ve bought. Remember to mark your account type (checking or savings). Payments to you will normally be made by direct deposit to the financial institution you designate. (This is also the account that will be debited when you choose Pay Direct as the method of payment on your tender.) Payments will be made by check if a payment is due to you before we have confirmed direct deposit arrangements for your account. If both the Legacy Treasury Direct account and the receiving financial institution account are in the names of individuals, then at least one of the individuals named on the Legacy Treasury Direct account must also be named on the deposit account at the receiving financial institution. The ROUTING NUMBER can be obtained at your financial institution or found on the bottom line of a check (see following example). When providing your ACCOUNT NUMBER, please include hyphens. A hyphen is generally represented on a check by the symbol " . 2 PD F 5182 E |
PD F 5182 E INSTRUCTIONS FOR COMPLETING Department of the Treasury Bureau of the Public Debt A NEW ACCOUNT REQUEST (Revised September 2009) We suggest you provide a voided check with this request. This PAUL MAPLE 1234 will enable us to verify your payment routing information—and LILIAN MAPLE 123 Main Street VOID prevent delays in your receipt of direct deposit payments. Anyplace, NY 10000 ORDER OFPAY TO THE Routing Account $ CAUTION: number number Some financial institutions use payment routing information DOLLARS which is not fully displayed on a check. ANYPLACE BANKAnyplace, NY 10000 For :250250025 :202020 86 1234 Note: The routing and account numbers may appear in different places on your check. 5. AUTHORIZATION This section must be signed and dated. Requests in the names of two individuals may generally be signed by either. However, if the second-named owner signs, then an IRS Form W-9 signed by the first-named owner must be submitted with the request. If the IRS has notified you that you are subject to backup withholding and you have not received notice from the IRS that backup withholding has terminated, you should strike out the language certifying that you are not subject to backup withholding. SUBMISSION Completed forms must be submitted to one of these Treasury Retail Securities Sites: Treasury Retail Securities Site Treasury Retail Securities Site PO Box 567 PO Box 9150 Pittsburgh, PA 15230-0567 Minneapolis, MN 55480-9150 CONTACT Call us toll-free in the United States at 1-800-722-2678. Outside the U.S.? Call us at (304) 480-6464. CONFIRMATION OF ESTABLISHED ACCOUNT You will receive a Legacy Treasury Direct ® Statement of Account confirming the establishment of your account. Enjoy the convenience of our Electronic Services for Treasury Bills, Notes, and Bonds from the comfort of your home using your computer (www.treasurydirect.gov) or a touch-tone phone (1-800-722-2678). Great hours! 8 am - 12 midnight ET, Monday through Friday, except for federal holidays (24 hours a day for Reinvest Direct®!) Here is what you can do: Buy a security • Request a duplicate interest income statement • Reinvest maturing securities • Order a S tatement of Account Get your overall account par balance (Web users get even more details) • Change your address and phone number, too. (Web users only) NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS 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 Public Debt 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 Public Debt 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 Public Debt, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form to the Bureau of the Public Debt; instead send it to your Treasury Retail Securities Site listed above. 3 PD F 5182 E |
PD F 5182 E INSTRUCTIONS FOR COMPLETING Department of the Treasury Bureau of the Public Debt A NEW ACCOUNT REQUEST (Revised September 2009) COMMON REGISTRATION OPTIONS Investors in marketable Treasury securities have a broad choice of registration options under Legacy Treasury Direct ®which are designed to address their needs and ownership situations. These options establish clear ownership and survivorship rights. Other options for natural guardians, custodians, IRAs, and government entities are available—for guidance, consult your Treasury Retail Securities Site. TO REGISTER YOUR SECURITY LIKE THIS: SELECT THIS OPTION: PROVIDE THIS: An account in the name of one individual. Single Ownership SSN Your name should appear the way you usually use it Mary Benson Doe (with at least one full given name). An account in the names of two people, joined by the Joint Ownership with SSN of the first-named word “and” and ending with “with right of survivorship.” Right of Survivorship owner This creates a conclusive right of survivorship. Both owners Elizabeth Black and Jane Brown, must authorize transaction requests. with right of survivorship An account in the names of two people, joined by the Joint Ownership without SSN of the first-named word “and” and ending with “without right of survivorship.” Right of Survivorship owner This does not create a right of survivorship. If one owner dies, John B. Butte and Mary B. Doe, his or her share passes on to the estate, not to the other owner. without right of survivorship Both owners must authorize transaction requests. An account in the names of two people, joined by the word “or.” Coo wnership SSN of the first-named This creates a conclusive right of survivorship. Either owner may James Black or Carolyn Black owner authorize transaction requests. An account in your name, followed by the words “payable Beneficiary SSN of the owner on death to” or “POD” another individual or the United States Jane Investor, payable on death Treasury (proceeds would then be used to reduce the public debt). to Junior Investory, a minor The beneficiary has no ownership rights prior to the owner’s death. You must identify the beneficiary’s status in the registra- Jack S. Jones, payable on death SSN of the owner tion if he or she is a minor or incompetent. The owner authorizes to Ellen H. Jones transaction requests. No consent from the beneficiary is needed. An account in the name of an executor, administrator, legal Estate Representative EIN or SSN of the decedent guardian, conservator or other representative of an estate. John Smith and Joseph Jones, You must make sure the name of the estate is adequately identi- Executors of the fied in the registration. If there are several representatives, you Will of James Brown, deceased may omit some by using language that indicates they exist. You may need to provide evidence when you open this type of account. Contact your Treasury Retail Securities Site. An account in the name of the trustee(s) of a trust. Trustees EIN or SSN of the first- Trusts may be created by wills, agreements, indentures, deeds, Robert C. Jones and named owner declarations of trust, or similar instruments. You must include Mary E. Doe, Trustees language that adequately identifies the authority or document by under declaration of trust which the trust was created. If there are several trustees, you may dated 9/2/76 omit some names as long as you include language that indicates they exist. You may need to provide evidence when you open this type of account. Contact your Treasury Retail Securities Site. An account in the name of a private corporation, Private Organizations EIN unincorporated association or partnership. The Standard Manufacturing You must include the full legal name and status (corporation, Corporation unincorporated association or partnership). You may reference a particular account or fund, other than a trust fund. 4 PD F 5182 E |