1000 Ownership Certificate

Form

1000

(Rev. September 2016)
Department of the Treasury
Internal Revenue Service

Ownership Certificate
OMB No. 1545-0054
▶

Information about Form 1000 is at www.irs.gov/uac/about-form-1000.

To be used by a U.S. citizen, resident individual, fiduciary, partnership, or nonresident partnership all of whose members are citizens or residents, in connection with
interest on bonds of a corporation containing a tax-free covenant and issued before January 1, 1934.
Owner of bonds

U.S. identifying number

Address of owner (number and street, city or town, state or province, country, ZIP or
foreign postal code)

I CERTIFY that to the best of my knowledge and belief, the
information entered on this form is correct.

Employer identification number

Name of withholding agent

U.S. address of withholding agent (number and street, city or town, state, and
ZIP code)

Name of bond and date of issue

Date interest due

Date interest paid

Signature of owner, fiduciary, trustee, or agent

Classes of Bond Owners

Address of fiduciary, trustee, or agent (number and street, city or
town, state or province, ZIP or foreign postal code)

Tax
Assumed
(2%)

Gross Amount
of Interest Paid

1 (a) Individual, estate, or trust, whose taxable income
If an estate or trust, enter name

For Paperwork Reduction Act Notice, see instructions.

2

exceeds the deductions for exemptions; or (b)
partnership . . . . . . . . . . .

$

Individual, estate, or trust, whose taxable income
does not exceed the deduction for exemptions . .

$

Cat. No. 17097D

$
No tax paid
by corporation
Form 1000 (Rev. 9-2016)

Form 1000 (Rev. 9-2016)

Instructions for Owner, Fiduciary, Trustee, or
Agent
Use a separate Form 1000 for each issue of bonds. If amended
certificates are necessary, forward them to the withholding agent by
February 1 of the following year.
Where to file. File this form with the withholding agent for interest
payments on bonds that have a tax-free covenant and that were
issued before 1934 by a domestic corporation or a resident or
nonresident foreign corporation.

Instructions for Withholding Agents
Use Form 1042 to summarize Forms 1000. Do not send Form 1000
to the IRS. Keep Form 1000 for at least 4 years after the end of the
last calendar year in which the income the form applies to is paid.
If a nonresident foreign corporation with a fiscal or paying agent
in the United States issues the obligation, modify Form 1000 to
show the name and address of the nonresident debtor corporation
in addition to the name and address of the U.S. fiscal or paying
agent.
Paperwork Reduction Act Notice. We ask for the information on
this form to carry out the Internal Revenue laws of the United

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2

States. You are required to give us the information. We need it to
ensure that you are complying with these laws and to allow us to
figure and collect the right amount of tax.
You are not required to provide the information requested on a
form that is subject to the Paperwork Reduction Act unless the form
displays a valid OMB control number. Books or records relating to a
form or its instructions must be retained as long as their contents
may become material in the administration of any Internal Revenue
law. Generally, tax returns and return information are confidential,
as required by Internal Revenue Code section 6103.
The time needed to complete and file this form will vary
depending on individual circumstances. The estimated average
time is: Recordkeeping, 3 hr., 6 min.; Learning about the law or
the form, 6 min.; Preparing the form, 9 min.
If you have comments concerning the accuracy of this time
estimate or suggestions for making this form simpler, we would be
happy to hear from you. You can send us comments from
www.irs.gov/formspubs. Click on “More Information” and then on
“Give us feedback.” You can write to the Internal Revenue Service,
Tax Forms and Publications, 1111 Constitution Ave. NW, IR-6526,
Washington, DC 20224. Do not send this form to this address.
Instead, see Where to file, earlier.