1000
Ownership Certificate
Form
(Rev. Dec. 2005)
OMB No. 1545-0054
Department of the Treasury
For Paperwork Reduction Act Notice, see back of form.
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 (Print or type name)
U.S. identifying number
Withholding agent (Print or type name)
Employer identification number
Address of owner (street, city, state, and ZIP code)
U.S. address of withholding agent (street, city, state, and 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 of
Classes of Bond Owners
Tax Assumed (2%)
Interest Paid
Address of fiduciary, trustee, or agent
1
(a) Individual, estate, or trust, whose taxable income
exceeds
the
deductions
for
exemptions;
or
(b) partnership
$
$
If an estate or trust, give name here
No tax paid
2
Individual, estate, or trust, whose taxable income
by corporation
does not exceed the deduction for exemptions
$
Note: If amended certificates are necessary, forward them to the withholding agent by February 1 of the following year.
Cat. No. 17097D