Form PD-F-4144 Subscription for purchase and issue of U S Treasury secu

PD F 4144 E
Department of the Treasury
Bureau of the Public Debt
(Revised August 2005)

OMB NO. 1535-0092

SUBSCRIPTION FOR PURCHASE AND ISSUE OF
U.S. TREASURY SECURITIES
STATE AND LOCAL GOVERNMENT SERIES
TIME DEPOSIT
See Instructions On Back

Pursuant to the provisions of the Department of the Treasury Circular, Public Debt Series No. 3-72, current revision (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

CHANGE

SUBSCRIPTION ISSUE AMOUNT: $

ISSUE DATE:

/
MM

/
DD

YY

ISSUER:
Underlying Bond Issue:
Taxpayer Identification Number:

–

Name:

Address:

City:

State:

ZIP Code:

Contact Person:
Telephone:

Fax:

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

City:

State:

ZIP Code:

Contact Person:
Fax:

Telephone:

(Organization)

(Name and Title)

(Signature)

(Date)

(Telephone)

FOR USE OF THE BUREAU OF THE PUBLIC DEBT

Rate Table Date:

Processed by:

Verified by:

RESET

U.S. TREASURY SECURITIES
STATE AND LOCAL GOVERNMENT SERIES
TIME DEPOSIT
Instructions
Bureau of the Public Debt
Special Investments Branch
200 Third Street
PO Box 396
Parkersburg, WV 26106-0396

Telephone Number: (304) 480-5299
Fax Number: (304) 480-5277
Internet Address: http://www.slgs.gov
E-Mail Address: opda-sib@bpd.treas.gov
Governing Regulations: 31 CFR Part 344

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 Public Debt 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. Public Debt will not accept subscriptions 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 Public Debt no later than 3:00 p.m., Eastern time, on the issue date.
Subscription Issue Amount: Total amount to be invested. Must be at least $1,000 and in increments of $1.
Issue Date: Purchase date of the securities. The issue date must be a business day.
Issuer: The government body for whom the securities are being purchased.
Underlying Bond Issue: Should include CUSIP number (if available), Bond Issuer, Bond Series.
Trustee Bank: The financial institution appointed as trustee to act on behalf of the Issuer. (Optional)
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 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 Public Debt, Forms Management Officer, Parkersburg, WV 26106-1328.