Form Pd F 5381 E - Treasury Marketable Securities Tender Form printable pdf download

OMB No. 1535-0069

PD F 5381 E

Legacy Treasury Direct

Department of the Treasury

Bureau of the Public Debt

(Revised June 2008)

TREASURY MARKETABLE SECURITIES TENDER

For Noncompetitive Purchases in Legacy Treasury Direct

1-800-722-2678

TYPE OR PRINT IN INK ONLY – TENDERS WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS

DEPARTMENT USE

1. NONCOMPETITIVE BID INFORMATION

2. Legacy Treasury Direct ACCOUNT NUMBER

TENDER NO.

(Must Be Completed)

(If NOT furnished, a new account will be opened.)

Par Amount:

RECEIVED BY/DATE

(Sold in units of $100)

ENTERED

3. TAXPAYER ID NUMBER

(Must Be Completed)

Social Security Number

Employer ID Number

(First-Named Owner)

APPROVED

4. TERM SELECTION

5. ACCOUNT NAME

(Fill in One)

(Must Be Completed)

ISSUE DATE

Bill

Select the number of

reinvestments

13-Week..........

CUSIP

912795-

26-Week..........

CUSIP

912828-

52-Week..........

Note

6. ADDRESS

FOREIGN

(For new account or changes to existing accounts.)

2-Year Note

New Address?

5-Year Note

10-Year Note

BACKUP

TIPS

REVIEW

5-Year

10-Year

City

ZIP Code

State

9. PURCHASE METHOD

7. TELEPHONE NUMBERS

(For new account or changes to existing accounts.)

(Must Be Completed)

New Phone Number?

CHECK #

Pay Direct

Home

Alternate

(Existing Legacy Treasury Direct Account Only)

Checks:

8. PAYMENT INFORMATION

(For new account only.)

Changes? Submit PD F 5178.

Make checks

payable to Legacy

Routing Number

Treasury Direct.

Personal checks are

acceptable ONLY for

Financial Institution Name

notes and TIPS.

Financial Institution Account Number

Other

Name on Account

Total Payment

0.00

Attached:

Account Type:

Checking

Savings

(Fill in One)

CHECKS ARE DEPOSITED IMMEDIATELY

10. AUTHORIZATION

Tender Submission: I submit this tender pursuant to the provisions of

(Must Be Completed – Original Signature Required)

Department of the Treasury Circulars, Public Debt Series Nos. 2-86 (31 CFR Part 357) and 1-93 (31 CFR Part 356), and the applicable offering

announcement. As the first-named owner and under penalties of perjury, I certify that: 1) The number shown on this form is my correct taxpayer

identification number (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 U.S. person (including

a U.S. resident alien). I further certify that all other information provided on this form is true, correct, and complete.

Certification instructions: You must cross out item 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.

Pay Direct: (If using this purchase method.) I authorize a debit to my account at the financial institution I designated in Legacy Treasury Direct to

pay for this security. I understand that the purchase price will be charged to my account on or after the settlement date. I also understand that if this

transaction cannot be successfully completed, my tender can be rejected, the transaction canceled, and a 1% penalty assessed. If there is a dispute,

a copy of this authorization may be provided to my financial institution.

Signature(s)

Date

RESET