PD F 5366 FHA New Account Request

RESET

PD F 5366E
Department of the Treasury
Bureau of the Public Debt
(Revised January 2003)

OMB No. 1535-0120

FHA NEW ACCOUNT REQUEST
INVESTOR INFORMATION

FOR DEPARTMENT USE

ACCOUNT NAME
ACCOUNT NUMBER

ENTERED BY

ADDRESS
APPROVED BY

DATE APPROVED
State

City

ZIP-CODE

TAXPAYER IDENTIFICATION NUMBER
OR

1ST NAMED OWNER
SOCIAL SECURITY NUMBER

EMPLOYER IDENTIFICATION NUMBER

CONTACT PERSON
NAME

TELEPHONE NUMBER

(

)

DIRECT DEPOSIT INFORMATION

ACCOUNT TYPE
(Check One)

ROUTING NUMBER

CHECKING
SAVINGS

(Limit 9 characters)

FINANCIAL INSTITUTION

(Limit 30 characters)

ACCOUNT NUMBER

(Limit 17 characters)

ACCOUNT NAME

(Limit 22 characters)

AUTHORIZATION
I submit this request pursuant to the provisions of 31 CFR Part 306 and 31 CFR Part 337.

Under penalties of perjury, I certify that the number shown on this form is my correct taxpayer identification
number and that I am not subject to backup withholding because (1) I have not been notified that I am subject to
backup withholding as a result of a failure to report all interest or dividends or (2) the Internal Revenue Service
has notified me that I am no longer subject to backup withholding. I further certify that all other information
provided on this form is true, correct and complete.

SIGNATURE
SEE INSTRUCTIONS FOR PRlVACY ACT AND PAPERWORK REDUCTION ACT

DATE

INSTRUCTIONS FOR COMPLETING

AN FHA NEW ACCOUNT REQUEST

PURPOSE
You may use this form to establish a HUD account. The Bureau of the Public Debt will establish and maintain your book-entry account for the
future deposit of debentures.
IMPORTANT NOTICES
This form cannot be used for the purchase of debentures or to request a change to an existing account.
Unless all the required information is provided legibly, there may be a delay in processing your request. To avoid delays, read the instructions carefully and
print in ink only.

TAXPAYER IDENTIFICATION NUMBER
Provide the taxpayer identification number required on tax returns and other documents submitted to the Internal Revenue Service. For individuals, this is
the social security number (SSN) of the person whose name appears FIRST on the account. In the case of a partnership, company, organization or trust,
the employer identification number assigned by the IRS is used.

DIRECT DEPOSIT INFORMATION
Enter the following information:
• ROUTING NUMBER (your financial institution's ABA identifying number)
• FINANCIAL INSTITUTION NAME (the name of the institution to which payments are to be made)
• ACCOUNT NUMBER (the account number at your financial institution)
• ACCOUNT TYPE (checking or savings)
• ACCOUNT NAME (the name as it appears on the account at your financial institution)
Payments to you will be made by direct deposit to the financial institution you designate. The ROUTING NUMBER can be obtained from the institution
or found on the bottom line of a check or deposit slip. When providing your account number, please include hyphens. A hyphen is represented by
the symbol '''.

AUTHORIZATION
Sign and date the request form. Requests in the names of two individuals may be signed by either. However, if the second-named owner
signs, then IRS Form W-9 signed by the first-named owner, must be submitted with the request. If the IRS has notified you that you are subject
to backup withholding and you have not received notice from the IRS that backup withholding has terminated, you should strike out
the language certifying that you are not subject to backup withholding.
SUBMISSION
Submit this request to:

Bureau of the Public Debt
Special Investments Branch
200 Third Street
P.O. Box 396
Parkersburg, WV 26106-0396

Telephone Number: (304) 480-5299
Fax Number: (304) 480-5277
Internet Address: http://www.publicdebt.treas.gov/spe/spe.htm
E-Mail Address: opda-sib@bpd.treas.gov

NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS

We’re asking for the information on this form to assist us in processing your securities transaction requests. Our authority comes from
31 U.S.C. Ch. 31 which authorizes the Treasury Department to borrow money to pay the public debt of the United States. Also, 26
U.S.C. 6109 requires us to use your SSN on certain forms when we report taxable income to IRS. It’s voluntary that you provide the
requested information, but without it, we may not be able to process your transaction requests. Information concerning your securities
holdings and transactions is considered confidential under Treasury regulations (31 CFR Part 323) and the Privacy Act. However, the
following routine uses of this information may include disclosure to the following persons or entities: agents and contractors who help
us manage the public debt; others entitled to the securities or payment; agencies (including disclosure through approved computer
matches) determining eligibility for benefits, finding persons we’ve lost contact with, or helping us collect debts; agencies for investiga­
tions or prosecutions; courts, counsel, and others for litigation and other proceedings; a Congressional office asking on your behalf;
and as otherwise authorized by law.
We estimate it will take you about 10 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 Public Debt, Forms
Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form to the above address; send to the correct address shown in the
instructions.