4144-7 SLGSafe Template worksheet

PD F 4144-7 E
Department of the Treasury
Bureau of the Public Debt
(Revised August 2005)

OMB NO. 1535-0092

SLGSafe® TEMPLATE WORKSHEET
U.S. TREASURY SECURITIES
STATE AND LOCAL GOVERNMENT SERIES

The SLGSafe Template Worksheet is designed to save you valuable time after you’ve opened SLGSafe. Please
complete, print, and sign the worksheet. Mail this template information along with your SLGSafe Application for Internet
Access to the Special Investments Branch, Bureau of the Public Debt, 200 Third Street, P.O. Box 396, Parkersburg, WV
26106-0396.
After we’ve received your completed worksheet, we’ll create your SLGSafe template. When you logon, the information
you’ve provided will automatically appear each time you subscribe for a new issue. It’s that easy!
TRUSTEE BANK
ABA Routing Number
Name of Organization:

Address:
City:

State:

ZIP Code:

State:

ZIP Code:

FINANCIAL INSTITUTION MANAGING ACH PAYMENTS
Name of Organization:

Address:

City:
Direct Deposit Payment Instructions
ABA Routing Number
Account Name:

Limit 22 characters

Account Number:

Limit 17 characters

Account Type

Checking

Savings

FINANCIAL INSTITUTION TRANSMITTING FUNDS FOR PURCHASE
ABA Routing Number
Name of Organization:
Contact Person:
Telephone: (

Fax:

E-Mail:

ORGANIZATION AUTHORIZATION
Name of Organization:
Name of Contact Person:
Title of Contact Person:

Telephone:

Signature:
Date:

For Use by the Bureau of the Public Debt
Template Number

Processed By
RESET

NOTICE UNDER THE PAPERWORK REDUCTION ACT

We estimate it will take you about 30 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.