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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.



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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 " .

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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.

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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.

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