FS Form 4144-5 SLGSafe Application for Internet Access

SLGSafe® APPLICATION FOR INTERNET ACCESS

OMB No. 1530-0065

U.S.TREASURY SECURITIES
STATE AND LOCAL GOVERNMENT SERIES
See Instructions on Back

SLGSafe is a secure electronic commerce Internet site designed by the Bureau of the Fiscal Service to give customers
the opportunity to manage their portfolios for U.S. Treasury Securities - State and Local Government Series (SLGS).
To apply for access, you must select one SLGSafe Access Administrator and a Back-up Access Administrator who
are responsible for designating users, updating user information, and forwarding the Application(s) with attached User
Acknowledgment(s) to the Special Investments Branch (SIB). Your Access Administrator must certify that all individuals
are authorized to conduct SLGSafe transactions for the organization.
One SLGSafe Application and User Acknowledgment(s) need to be completed for each business address. Your Access
Administrator must mail the Application and User Acknowledgment(s) to the Special Investments Branch, Bureau of
the Fiscal Service, 200 Third Street, P.O. Box 396, Parkersburg, WV 26102-0396. You may also complete a
SLGSafe Template Worksheet and mail it with your Application. The completed worksheet will be used to create a
SLGSafe tem-plate so your information will automatically appear each time you subscribe for a new issue.
After SIB has approved the Application and the User Acknowledgment(s), each user will be contacted and given a User
ID with instructions on connecting to SLGSafe. The User ID, together with a password each user will create, provides
security by verifying the identity of each individual user. Users must agree to comply with 31 CFR Part 344, SLGSafe
Application for Internet Access, the SLGSafe Internet User’s Guide, as well as legal and privacy notices.
The Access Administrator must keep a copy of this Application and of the User Acknowledgment(s) on file for a period of
seven years and must make these documents available for examination by SIB upon request.
ACTION REQUESTED
Establish New User(s)
Delete User(s)
Other

ORGANIZATION INFORMATION
Type of Organization
Bank

ABA Routing Number

State or Local Government Body
Taxpayer Identification Number

–

Other
Taxpayer Identification Number

FS Form 4144-5

–

Department of the Treasury | Bureau of the Fiscal Service

Revised February 2016

All users on the attached SLGSafe User Acknowledgment(s) must have the following address:
Organization Name:
Business Address:
City:

State:

ZIP Code:

State:

ZIP Code:

SLGSafe ACCESS ADMINISTRATOR INFORMATION
SLGSafe Access Administrator’s Name (First, MI, Last):
Title:
Address:
City:
Telephone:

Fax:

E-Mail:

Back-up SLGSafe Access Administrator’s Name (First, MI, Last):
Title:
Address:
City:

State:

Telephone:

Fax:

ZIP Code:
E-Mail:

The Access Administrator certifies that pursuant to 31 CFR Part 344, the following individuals, whose names, titles,
original signatures, and telephone numbers appear on the SLGSafe User Acknowledgment(s) attached hereto and
incorporated herein, are authorized by resolution or by-laws of the Board of Directors, or other official authorization,
to submit SLGSafe transactions, on behalf of the organization. This authorization shall remain in effect until a written
notice of change in said authorization is received by SIB.
Under penalty of perjury, I certify that the information provided on this Application is correct and that all users are
authorized by the organization to sign for all SLGSafe transactions.
Number of User Acknowledgment(s) attached (

)
Official Seal or Stamp

Access Administrator’s Signature

(such as corporate seal,
signature guaranteed
stamp, or medallion stamp)

Backup Access Administrator’s Signature
Date

FOR USE BY THE BUREAU OF THE FISCAL SERVICE
Approved and Processed By:

Signature and Date

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. DO NOT SEND completed form to this address; send to the correct address shown in the
instructions.
FS Form 4144-5

Department of the Treasury | Bureau of the Fiscal Service

Revised February 2016

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