Form PD-F-5237 Subscription for purchase of U.S. Treasury securities st

PD F 5237 E
Department of the Treasury
Bureau of the Public Debt
(Revised January 2003)

SUBSCRIPTION FOR PURCHASE OF U.S. TREASURY SECURITIES

STATE AND LOCAL GOVERNMENT SERIES

ONE-DAY CERTIFICATE OF INDEBTEDNESS

DEMAND DEPOSIT

OMB NO. 1535-0082

See Instructions on Back
Pursuant to the provisions of the Department of the Treasury Circular, Public Debt Series No. 3-72, current revision (31 CFR Part
344), the undersigned hereby subscribes for the purchase of U.S. Treasury Securities - State and Local Government Series One-Day
Certificate of Indebtedness with the issue date and in the amount shown below, such issue to be in book-entry form on the books
of the Bureau of the Public Debt, Department of the Treasury.
SUBSCRIPTION STATUS: (Check one)

NEW

CHANGE

SUBSCRIPTION ISSUE AMOUNT: $

CANCEL

ISSUE DATE:

/
MM

/
DD

YY

STATE OR LOCAL GOVERNMENT BODY:
Taxpayer Identification Number:

–

Name:
Address:
City:
Contact Person:

State:

Telephone:

Fax:

ZIP Code:

TRUSTEE BANK: (As appointed by State or Local Government Body)
ABA Routing Number:
Name:
Address:

City:

State:

ZIP Code:

Contact Person:

Telephone:

Fax:

FINANCIAL INSTITUTION TRANSMITTING FUNDS FOR PURCHASE:
ABA Routing Number:

Name:

Contact Person:

Telephone:

Fax:

(Organization)
(Name and Title)

(Signature)

(Date)

(Telephone)

FOR USE OF THE BUREAU OF THE PUBLIC DEBT
Processed by:

Verified by:

RESET

U.S. TREASURY SECURITIES STATE AND LOCAL GOVERNMENT SERIES

ONE-DAY CERTIFICATE OF INDEBTEDNESS

DEMAND DEPOSIT

Instructions

Bureau of the Public Debt
Special Investments Branch
200 Third Street
PO Box 396
Parkersburg, WV 26106-0396

Telephone Number: (304) 480-5299
Fax Number: (304) 480-5277
Internet Address: http://www.slgs.gov
E-Mail Address: [email protected]
Governing Regulations: 31 CFR Part 344

For information on subscribing electronically, visit our website listed above.
Subscription Status:
• Check “New” if this is the first notification of the intent to purchase these State and Local Government Series securities. A new subscription must
be received by Public Debt at least five days before the issue date for subscriptions of $10 million or less, and at least seven days before the
issue date for subscriptions of over $10 million. Public Debt will not accept a new subscription received more than 60 days prior to the issue date.
• Check “Change” if you are submitting a change of information on a subscription which was previously submitted but not yet issued. Changes to
the subscription must be received by Public Debt no later than 3:00 p.m., Eastern time, on the issue date. Changes to the issue date must be
received no later than 3:00 p.m., Eastern time, one business day before the originally specified issue date.
• Check “Cancel” if you wish to cancel a subscription which has previously been submitted but not yet issued. Subscriptions for $10 million or
less can be cancelled without penalty up to five days prior to the issue date. Subscriptions for more than $10 million can be cancelled without
penalty up to seven days prior to the issue date. IF THESE REQUIREMENTS ARE NOT MET A PENALTY WILL BE IMPOSED FOR THE
CANCELLATION OF A SUBSCRIPTION PER 31 CFR Part 344.
Issue Date: Purchase date of the securities. The issue date must be a business day.

Issue Amount: Total amount to be invested. Must be at least $1,000.
State or Local Government Body: The government body for whom the securities are being purchased.
Trustee Bank: The financial institution appointed as trustee to act on behalf of the State or Local Government Body. (Optional)
Financial Institution Transmitting Funds For Purchase: Financial institution designated by the owner or the trustee bank to transmit funds via the
Fedwire system to purchase the securities. The following information must be entered on the Fedwire system to transfer funds to the Bureau of the
Public Debt. Payment should be received by 3:00 p.m., Eastern time, on the issue date.
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Your bank’s ABA routing number for the “SENDER ABA”.
Your organization name for the “SENDER NAME”.
ABA ROUTING NUMBER 051036476 FOR THE “RECEIVER ABA”.
TREAS BPD SIB for the “RECEIVER NAME”.
1000 for the “TYPE CODE”.
Amount of payment for the "AMOUNT" field.
BTR for the “BUS. FUNCTION CODE”.
Name of financial Institution Acting as Trustee for the “ORIGINATOR NAME” field.
Name of the Owner (State or Local Government Entity) for the “BENEFICIARY NAME” field.
Issue Date of subscription package in MMDDYY format for the “ORIG TO BENEF INFO” field.
Taxpayer Identification Number (the TIN of the State or Local Government Entity, NOT the Financial Institution)
in the “FI to FI INFO” field.

Organization: Organization submitting the subscription for purchase.
Name and Title: The typed or printed name and title of the person authorized to purchase securities on behalf of the State or Local
Government Body.
Signature, Date, and Telephone: The signature, date, and telephone number of the person authorized to purchase securities on behalf
of the State or Local Government Body.

NOTICE UNDER PAPERWORK REDUCTION ACT
We estimate it will take you about 08 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.