Form Pd F 5381 E - Treasury Marketable Securities Tender - 2011

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Legacy Treasury Direct

PD F 5381 E

OMB No. 1535-0069

Department of the Treasury

Bureau of the Public Debt

TREASURY MARKETABLE SECURITIES TENDER

(Revised May 2011)

For Noncompetitive Purchases in Legacy Treasury Direct

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

(Must Be Completed)

Par Amount:

TENDER NO.

(Must Be Completed)

RECEIVED BY/DATE

(Sold in units of $100)

3. TAXPAYER ID NUMBER

ENTERED

(Must Be Completed)

Social Security Number (First-Named Owner)

Employer ID Number

5. ACCOUNT NAME

4. TERM SELECTION

(Must Be Completed)

(Fill in One)

APPROVED

(Must Be Completed)

Bill

(Select the number of

reinvstments)

13-Week . . .

ISSUE

DATE

26-Week . . .

Note: The Department of the Treasury plans to stop

purchases and reinvestments in Legacy Treasury

CUSIP

Direct no later than November 1, 2012.

912795-

6. TELEPHONE NUMBERS

7. ADDRESS

(For changes to existing accounts.)

FOREIGN

Home

BACKUP

Alternate

ZIP Code

City

State

REVIEW

8. PURCHASE METHOD

(Must Be Completed)

Checks:

Pay Direct

CHECK #

Cashier’s or certified

checks only. Make

payable to “Legacy

Treasury Direct.”

Total Payment Attached: $

0.00

CHECKS ARE DEPOSITED IMMEDIATELY

9. AUTHORIZATION

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

(Must Be Completed – Original Signature Required)

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 firstnamed

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