Pd F 5381 Treasury Marketable Securities Tender

Legacy Treasury Direct®

PD F 5381 E
Department of the Treasury
Bureau of the Public Debt
(Revised November 2008)

OMB No. 1535-0069

TREASURY MARKETABLE SECURITIES TENDER

www.treasurydirect.gov
1-800-722-2678

For Noncompetitive Purchases in Legacy Treasury Direct

TYPE OR PRINT IN INK ONLY – TENDERS WILL NOT BE ACCEPTED WITH ALTERATIONS OR CORRECTIONS
1. N
 ONCOMPETITIVE BID INFORMATION
(Must Be Completed)
Par Amount:

DEPARTMENT USE

2. Legacy Treasury Direct ACCOUNT NUMBER

TENDER NO.

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

$

RECEIVED BY/DATE

(Sold in units of $100)

3. TAXPAYER ID NUMBER

ENTERED
BY

(Must Be Completed)

OR

Social Security Number (First-Named Owner)

4. TERM SELECTION
(Must Be Completed)

5. ACCOUNT NAME

(Fill in One)

Employer ID Number
APPROVED
BY

(Must Be Completed)
ISSUE DATE

(Select the number
of reinvestments)

Bill

13-Week . . . 0

26-Week . . . 0

52-Week . . . 0

CUSIP
912795-

CUSIP
912828-

Note

6. ADDRESS

2-Year Note

5-Year Note

3-Year Note

10-Year Note

(For new account or changes to existing accounts.)

FOREIGN

New Address?

BACKUP

TIPS

5-Year

REVIEW

10-Year

7. TELEPHONE NUMBERS

City

(For new account or changes to existing accounts.)

Home

Alternate
(For new account only.)

Changes? Submit PD F 5178.

Financial Institution Name
Financial Institution Account Number
Name on Account
(Fill in One)

Pay Direct *

Checks:

CHECK #

$

Make checks
payable to Legacy
Treasury Direct.
Personal checks
are acceptable
ONLY for notes
and TIPS.

$

$

Other:

$
$

Total Payment Attached: $

Checking

(Must Be
Completed)

(Existing Legacy Treasury Direct Account Only)

Routing Number

Account Type:

9. PURCHASE METHOD

®

New Phone Number?

8. PAYMENT INFORMATION

ZIP Code

State

Savings

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 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

NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
The collection of the information you are requested to provide on this form is authorized by 31 U.S.C. Ch. 31 relating to the public debt of the United States. The furnishing of
a social security number, if requested, is also required by Section 6109 of the Internal Revenue Code (26 U.S.C. 6109).
The purpose of requesting the information is to enable the Bureau of the Public Debt and its agents to issue securities, process transactions, make payments, identify owners
and their accounts, and provide reports to the Internal Revenue Service. Furnishing the information is voluntary; however, without the information Public Debt may be unable
to process transactions.
Information concerning securities holdings and transactions is considered confidential under Treasury regulations (31 CFR, Part 323) and the Privacy Act. This information
may be disclosed to a law enforcement agency for investigation purposes; courts and counsel for litigation purposes; others entitled to distribution or payment; agents and
contractors to administer the public debt agencies or entities for debt collection or to obtain current addresses for payment; agencies through approved computer matches;
Congressional offices in response to an inquiry by the individual to whom the record pertains; as otherwise authorized by law or regulation.
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 Legacy Treasury Direct® which are designed to address their needs and
ownership situations. These options establish clear ownership and survivorship rights. Other options for natural guardians, custodians, IRA’s, and government entities
are available—for guidance, consult the Legacy Treasury Direct Investor Kit (PD P 009) or your Treasury Retail Securities Site. 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
(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

For Tender Instructions, See PD F 5382

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