FS Form 5366 FHA New Account Request

OMB No. 1530-0054

FHA NEW ACCOUNT REQUEST

INVESTOR INFORMATION

FOR DEPARTMENT USE

ACCOUNT NAME

ACCOUNT NUMBER

ENTERED BY

ADDRESS
APPROVED BY

DATE APPROVED

TAXPAYER IDENTIFICATION NUMBER
1st NAMED OWNER

SOCIAL SECURITY NUMBER

or

EMPLOYER IDENTIFICATION NUMBER

CONTACT PERSON
NAME

TELEPHONE NUMBER

(

)

DIRECT DEPOSIT INFORMATION

ACCOUNT TYPE
(Check One)

ROUTING NUMBER

CHECKING
SAVINGS

(Limit 9 characters)

FINANCIAL INSTITUTION NAME
ACCOUNT NUMBER
ACCOUNT NAME

(Limit 30 characters)

(Limit 17 characters)

(Limit 22 characters)

AUTHORIZATION
I submit this request pursuant to the provisions of 31 CFR Part 306 and 31 CFR Part 337.
Under penalties of perjury, I certify that the number shown on this form is my correct taxpayer identification number and that I am
not subject to backup withholding because (1) I have not been notified that I am subject to backup withholding as a result of a
failure to report all interest or dividends or (2) the Internal Revenue Service has notified me that I am no longer subject to backup
withholding. I further certify that all other information provided on this form is true, correct and complete

SIGNATURE
SEE INSTRUCTIONS FOR PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE

FS Form 5366

Department of the Treasury | Bureau of the Fiscal Service

DATE

RESET
Revised February 2016

INSTRUCTIONS FOR COMPLETING
AN FHA NEW ACCOUNT REQUEST
PURPOSE
You may use this form to establish a HUD account. The Bureau of the Fiscal Service will establish and maintain your book-entry
account for the future deposit of debentures.
IMPORTANT NOTICES
This form cannot be used for the purchase of debentures or to request a change to an existing account.
Unless all the required information is provided legibly, there may be a delay in processing your request. To avoid delays, read the
instructions carefully and print in ink only.

TAXPAYER IDENTIFICATION NUMBER
Provide the taxpayer identification number required on tax returns and other documents submitted to the Internal Revenue Service.
For individuals, this is the social security number (SSN) of the person whose name appears FIRST on the account. In the case of a
partnership, company, organization or trust, the employer identification number assigned by the IRS is used.

DIRECT DEPOSIT INFORMATION
Enter the following information:
• ROUTING NUMBER (your financial institution’s ABA identifying number)
• FINANCIAL INSTITUTION NAME (the name of the institution to which payments are to be made)
• ACCOUNT NUMBER (the account number at your financial institution)
• ACCOUNT TYPE (checking or savings)
• ACCOUNT NAME (the name as it appears on the account at your financial institution)
Payments to you will be made by direct deposit to the financial institution you designate. The ROUTING NUMBER can be obtained
from the institution or found on the bottom line of a check or deposit slip. When providing your account number, please include
hyphens. A hyphen is represented by the symbol ‘’’.

AUTHORIZATION
Sign and date the request form. Requests in the names of two individuals may be signed by either. However, if the second-named
owner signs, then IRS Form W-9 signed by the first-named owner, must be submitted with the request. If the IRS has notified you
that you are subject to backup withholding and you have not received notice from the IRS that backup withholding has terminated,
you should strike out the language certifying that you are not subject to backup withholding.
SUBMISSION
Submit this request to:

Bureau of the Fiscal Service
Special Investments Branch
200 Third Street
P.O. Box 396
Parkersburg, WV 26102-0396

Telephone Number: (304) 480-5299
Fax Number: (304) 480-5277
E-Mail Address: [email protected]

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 or 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 Fiscal Service, Forms Management Officer, Parkersburg,
WV 26106-1328. DO NOT SEND completed form to this address; send to the correct address shown in the instructions.

FS Form 5366

Department of the Treasury | Bureau of the Fiscal Service

Revised February 2016