FS Form 4144-6 SLGSafe User Acknowledgement

OMB No. 1530-0065

SLGSafe® USER ACKNOWLEDGEMENT
SLGSafe® APPLICATION FOR INTERNET ACCESS
U.S.TREASURY SECURITIES
STATE AND LOCAL GOVERNMENT SERIES

By signing this acknowledgment, I certify that I understand and am bound by the requirements and responsibilities
regarding the use of a User ID and Password to conduct SLGSafe transactions on behalf of
(hereinafter the “organization”).
I agree that each time I submit a SLGSafe transaction, I am certifying that it is in compliance with the requirements and
responsibilities set forth in applicable laws and regulations, including 31 CFR Part 344, Fiscal Service’s legal and
privacy notices and, the SLGSafe Application for Internet Access. I have read and understand the aforementioned
conditions of use which may change over time.
I also agree to ensure my User ID and Password remains confidential as specified in the SLGSafe Internet User’s Guide.
If I suspect that the confidentiality of my User ID and Password has been compromised, I will immediately notify Fiscal
Service’s Help Desk at (304) 480-7777.
Finally, I agree that the use of a User ID and Password to create an electronic message in SLGSafe means that it: (1)
identifies and authenticates a particular person as the source of the electronic message; and (2) indicates such person’s
approval of the information contained in the electronic message. Any SLGSafe electronic message to which it is affixed
or attached may not be denied legal effect, including legal effect as a signature, a writing, or an original, solely because
the message is in electronic form.
I understand that any failure to comply with the conditions of use may result in suspension of the organization from
access to SLGSafe.

Name (First, MI, Last):
Title:
Telephone::

Fax:

E-Mail:
Mother’s Maiden Name:
Signature:

Date:

Forward completed form to your SLGSafe Access Administrator who will attach it to the SLGSafe Application for Internet Access.

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 Fiscal Service, Forms Management Officer, Parkersburg, WV 26106-1328.
FOR USE BY THE BUREAU OF THE FISCAL SERVICE
E-Customer ID

FS Form 4144-6

Processed by

Department of the Treasury | Bureau of the Fiscal Service

Revised February 2016

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