1. RRB Claim Number
2. Payee Code
3. Your United States Taxpayer
4. Name and Address
OMB NO. 3220-0145
5. Claimed country of citizenship.
6. Claimed country of legal residence.
Note: If this is different than the country
shown In Item 4, you must submit proof of
7. Do you claim exemption under any tax treaty in effect between
your country of legal residence and the United States?
Note: To receive an exemption, you must comply with certain
requirements. See Form TB-26 for more information about
claiming an exemption.
8. United States Passport Number only
Note: Passport cannot be expired.
9. I understand that making a false or fraudulent statement to the RRB is a
crime punishable by Federal law. I certify that the information provided on
this certificate is true, complete, and correct. I will notify the RRB within 30
days of any change in this information.
This certificate MUST BE SIGNED to be valid.
Form RRB-1001 (xx-xx)