Form FS Form 3871 FS Form 3871 Application For Issue Of United States Mortgage Guaranty

OMB No. 1530-0052

APPLICATION FOR ISSUE OF UNITED STATES
MORTGAGE GUARANTY INSURANCE
COMPANY TAX AND LOSS BONDS
To: Bureau of the Fiscal Service, Special Investments Branch, P.O. Box 396, Parkersburg, WV 26102-0396

Phone (304) 480-5299, Fax (304) 480-5277

RESET

Pursuant to the provisions of Department of the Treasury Circular, No. 300 (31 CFR Part 306), to the extent applicable.

Issue Amount $

Dated

10 Year

Issue Date

20 Year

(Must be 10 or 20 years from issue date.)

this

day of
(Month)

(Year)

Name of Owner

Signature and Title of Officer

Telephone Number (Include Area Code)

Purchaser (Name of Owner)
TIN

–

SUFFIX

(Leave blank if first time purchase.)

Name
Address

City

State

ZIP Code

City

State

ZIP Code

Financial Institution
Name
Address

Contact Name

Phone Number

Direct Deposit (ACH) information for Payment at Maturity
Account Name
Account Number
Routing Number
Account Type

Checking

Savings

FOR THE USE OF THE BUREAU OF THE FISCAL SERVICE
TREASURY CASE NO.

FS Form 3871

ISSUE DATE

MATURITY DATE

Department of the Treasury | Bureau of the Fiscal Service

APPROVED BY

Revised August 2015

OMB No. 1530-0052

U.S TREASURY SECURITIES
UNITED STATES MORTGAGE GUARANTY INSURANCE COMPANY TAX AND LOSS BONDS

FUNDS TRANSACTION
FOR ADDITIONAL HELP IN FILLING OUT THIS FORM PHONE (304) 480-5299

INSTRUCTIONS FOR TRANSMITTING PAYMENT FOR SECURITIES:
The following information must be entered on the Fedwire system to transfer funds to the Bureau of the Fiscal Service.
• Your bank’s ABA routing number for the “SENDER ABA”.
• Your organization name for the “SENDER NAME”.
• ABA routing number 051036476 for the “RECEIVER ABA”.
• TREAS BFS SIB for the “RECEIVER NAME”.
• BTR for the “PRODUCT-CODE”.
• 1000 for the “TYPE CODE”.
• The name of the owner must be placed in the “ORIGINATOR’S NAME” field.
• The name of the bank submitting funds must be placed in the “ORIGINATOR’S” field.
• The owner’s taxpayer identification number must be placed in the “REFERENCE TO THE BENEFICIARY” field.
• The issue date must be placed in the “ORIGINATOR TO BENEFICIARY INFORMATION” field.

NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
The collection of the information you are requested to provide on this form is authorized by 31 U.S.C. Ch. 31 relating to the public debt of the United States.
The furnishing of a social security number, if requested, is also required by Section 6109 of the Internal Revenue Code (26 U.S.C. 6109).
The purpose for requesting the information is to enable the Bureau of the Fiscal Service and its agents to issue securities, process transactions, make payments,
identify owners and their accounts, and provide reports to the Internal Revenue Service. Furnishing the information is voluntary; however, without the information
Fiscal Service may be unable to process transactions.
Information concerning securities holdings and transactions is considered confidential under Treasury regulations (31 CFR, Part 323) and the Privacy Act. This
information may be disclosed to a law enforcement agency for investigation purposes; courts and counsel for litigation purposes; others entitled to distribution
or payment; agents and contractors to administer the public debt; agencies or entities for debt collection or to obtain current addresses for payment; agencies
through approved computer matches; Congressional offices in response to an inquiry by the individual to whom the record pertains; as otherwise authorized by
law or regulation.
We estimate that it will take you about 15 minutes to complete this form. This includes the time it will take to read the instructions, gather the necessary
facts and fill out the form. If you have comments or suggestions regarding the above estimate or ways to simplify this form, forward correspondence
to Bureau of the Fiscal Service, Forms Management Officer, Parkersburg, WV 26102-1328 and the Office of Management and Budget, Paperwork
Reduction Project 1535-0126, Washington, DC 20503.

FS Form 3871

Department of the Treasury | Bureau of the Fiscal Service

Revised August 2015