FS Form 5237 Subscription for Purchase of U.S. Treasury Securities St

OMB No. 1530-0065

SUBSCRIPTION FOR PURCHASE OF U.S. TREASURY SECURITIES
STATE AND LOCAL GOVERNMENT SERIES
ONE-DAY CERTIFICATE OF INDEBTEDNESS
DEMAND DEPOSIT
See Instructions on Back

Pursuant to the provisions of 31 CFR Part 344, the undersigned hereby subscribes for the purchase of State and Local Government
Series securities. The undersigned certifies that this subscription complies with the requirements in 31 CFR Part 344.
SUBSCRIPTION STATUS: (Check one)

NEW

SUBSCRIPTION ISSUE AMOUNT: $

CHANGE
ISSUE DATE:

MM / DD / YYYY

ISSUER:
Underlying Bond Issue:
Taxpayer Identification Number:

–

Name:
Address:
State:

City:
Contact Person:
Telephone:

ZIP Code:

-

ZIP Code:

-

Fax:

TRUSTEE BANK: (As appointed by the Issuer)
ABA Routing Number:
Name:
Address:

State:

City:
Contact Person:

Fax:

Telephone:

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

Fax:

(Organization)
(Name and Title)
(Signature)

Processed by:
FS Form 5237

(Date)

(Telephone)

FOR BUREAU OF THE FISCAL SERVICE USE ONLY

RESET

Verified by:
Department of the Treasury | Bureau of the Fiscal Service

Revised February 2016

U.S. TREASURY SECURITIES STATE AND LOCAL GOVERNMENT SERIES
ONE-DAY CERTIFICATE OF INDEBTEDNESS
DEMAND DEPOSIT
Instructions
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

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

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 Fiscal Service 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. Fiscal Service 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 Fiscal Service no later than 3:00 p.m., Eastern time, on the issue date.

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.
Issuer: The government body for whom the securities are being purchased.
Underlying Bond Issue: Should include CUSIP number (if available), Bond Issuer, and Bond Series.
Trustee Bank: The financial institution appointed as trustee to act on behalf of the issuer. (Optional)
Financial Institution Transmitting Funds For Purchase: Financial institution designated by the issuer or the trustee bank to transmit funds via the
Fedwire system to purchase the securities. Payment should be received by 3:00 p.m., Eastern time, on the issue date. The following information
must be entered on the Fedwire system to transfer funds to the Bureau of the Fiscal Service.
•
•
•
•
•
•
•
•
•
•
•

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 BFS 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 Issuer 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 Issuer, 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 Issuer.
Signature, Date, and Telephone: The signature, date, and telephone number of the person authorized to purchase securities on behalf
of the Issuer.

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 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 5237

Department of the Treasury | Bureau of the Fiscal Service

Revised February 2016