5381 Treasury Bill & Note Tender

PD F 5381 E
Department of the Treasury

Bureau of the Public Debt

(Revised March 2003)

OMB No. 1535-0069

TREASURY BILL & NOTE TENDER

www.treasurydirect.gov

1-800-722-2678

For Tender Instructions, See PD F 5382

TYPE OR PRINT IN INK ONLY – TENDERS WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS
1. BID INFORMATION
Par Amount:

DEPARTMENT USE
TENDER NO.

(Must Be Completed)

Bid Type:

Noncompetitive

(Fill in One)

Competitive at

$
(Sold in units of $1,000)

.

%

RECEIVED BY/DATE

(A bid for a bill must end in 0 or 5, see Tender instructions.)

2. TreasuryDirect ACCOUNT NUMBER

3. TAXPAYER ID NUMBER

ENTERED
BY

(Must Be Completed)

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

-

OR

4. TERM SELECTION

5. ACCOUNT NAME

(Fill in One)

APPROVED
BY

Employer ID Number

Social Security Number (First-Named Owner)
(Must Be Completed)

(Must Be Completed)

Bill

ISSUE DATE

Circle the Number of
Reinvestments
CUSIP
912795-

13-Week.......... 0
26-Week.......... 0

CUSIP
912828-

Note

FOREIGN

6. ADDRESS

2-Year Note

(For new account or changes to existing accounts.)

New Address?

3-Year Note

BACKUP

5-Year Note
10-Year Note

REVIEW

Inflation-Indexed
City

7. TELEPHONE NUMBERS

(For new account or changes to existing accounts.)

Pay DIrect

Alternate

8. PAYMENT INFORMATION

(For new account only.)

Changes? Submit PD F 5178.

Checks:
Make checks
payable to
TreasuryDirect.
Personal checks
are acceptable
ONLY for notes.

Financial Institution Name
Account Number

Other

Name on Account
(Fill in One)

CHECK #

®

(Existing TreasuryDirect Account Only)

Routing Number

Account Type:

9. PURCHASE METHOD
(Must Be Completed)

New Phone Number?

Home

ZIP Code

State

Checking

Savings

Total Payment
Attached:

$
$
$
$
$

0.00

CHECKS ARE DEPOSITED IMMEDIATELY

10. AUTHORIZATION

(Must Be Completed – Original Signature Required) Tender Submission: I submit this tender 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), 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 TreasuryDirect 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

NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
We’re asking for the information on this form to assist us in processing your securities transaction requests. Our authority comes from 31 U.S.C. Ch. 31 which authorizes
the Treasury Department to borrow money to pay the public debt of the United States. Also, 26 U.S.C. 6109 requires us to use your SSN on certain forms when we report
taxable income to IRS. It’s voluntary that you provide the requested information, but without it, we may not be able to process your transaction requests. Information
concerning your securities holdings and transactions is considered confidential under Treasury regulations (31 CFR Part 323) and the Privacy Act. However, the following
routine uses of this information may include disclosure to the following persons or entities: agents and contractors who help us manage the public debt; others entitled to
the securities or payment; agencies (including disclosure through approved computer matches) determining eligibility for benefits, finding persons we’ve lost contact with, or
helping us collect debts; agencies for investigations or prosecutions; courts, counsel, and others for litigation and other proceedings; a Congressional office asking on your
behalf; and as otherwise authorized by law.
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 above address; send to the correct address shown in the instructions (PD F 5382).

Common Registration Options
Investors in marketable Treasury securities have a broad choice of registration options under TreasuryDirect which are designed to address
their needs and ownership situations. These options establish clear ownership and survivorship rights. Other options are available—for
guidance, consult the TreasuryDirect Investor Kit (PD P 009) or your TreasuryDirect office. Remember: If you have two names in the registration
and don’t include a connective (and, or, or POD), we will reject the tender. Also, when using “and” in the registration, include “with right of
survivorship” or “without right of survivorship.” If you don’t, “without” will be used when the account is established.

To register your security like this:

Select this option:

Provide this:

An account in the name of one individual.
Your name should appear the way you usually use it
(preferably with at least one full given name).

Single Ownership
Mary Benson Doe

SSN

An account in the names of two people, joined by the word
“and” and ending with “with right of survivorship.”
This creates a conclusive right of survivorship. Both
owners must authorize transaction requests.

Joint Ownership with
Right of Survivorship
Elizabeth Black and Jane Brown,
with right of survivorship

An account in the names of two people, joined by the word
“and” and ending with “without right of survivorship.”
This does not create a right of survivorship. If one owner

dies, his or her share passes on to the estate, not to the other owner.

Both owners must authorize transaction requests.

Joint Ownership Without
Right of Survivorship
John B. Butte and Mary B. Doe,
without right of survivorship

An account in the names of two people, joined by the

word “or.” This creates a conclusive right of survivorship.

Either owner may authorize transaction requests.

Co-ownership
James Black or Carolyn Black

An account in your name, followed by the words “payable

on death to” or “POD” another individual or the United States

Treasury (proceeds would then be used to reduce the public debt).

The beneficiary has no ownership rights prior to the owner’s death.

You must identify the beneficiary’s status in the registration

if he or she is a minor or incompetent. The owner authorizes

transaction requests. No consent from the beneficiary is needed.

Beneficiary
Jane Investor, payable on death to
Junior Investor, a minor

An account in the name of an executor, administrator, legal
guardian, conservator or other representative of an estate.
You must make sure the name of the estate is adequately identified

in the registration.

Estate Representative
John Smith and Joseph Jones,

Executors of the

Will of James Brown, deceased

An account in the name of the trustee(s) of a trust. Trusts

may be created by wills, agreements, indentures, deeds,

declarations of trust, or similar instruments. You must

include language that adequately identifies the

authority or document by which the trust was created.

Trustees
Robert C. Jones and
Mary E. Doe, Trustees
under declaration of trust
dated 9/2/76

An account in the name of a private corporation,

unincorporated association or partnership. You must

include the full legal name and status (corporation, unincorporated

association or partnership). You may reference a particular

account or fund, other than a trust fund.

Private Organizations
The Standard Manufacturing
Corporation

Jack S. Jones, payable
on death to Ellen H. Jones

and Pay Direct ® are registered trademarks of the Bureau of the Public Debt.

SSN of the first-named owner

SSN of the first-named owner

SSN of the first-named owner

SSN of the owner

SSN of the owner

EIN or SSN of the decedent

EIN or SSN of the first-named owner

EIN