Form 1000 - Ownership Certificate

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Ownership Certificate
OMB No. 1545-0054
(Rev. September 2016)
Department of the Treasury
Information about Form 1000 is at
Internal Revenue Service
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)
Name of bond and date of issue
Date interest due
Date interest paid
I CERTIFY that to the best of my knowledge and belief, the
information entered on this form is correct.
Signature of owner, fiduciary, trustee, or agent
Gross Amount
Classes of Bond Owners
of Interest Paid
Address of fiduciary, trustee, or agent (number and street, city or
town, state or province, ZIP or foreign postal code)
(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.
(Rev. 9-2016)
Cat. No. 17097D


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