4144-5 SLGSafe Application for internet access

PD F 4144-5 E
Department of the Treasury
Bureau of the Public Debt
(Revised July 2005)

OMB NO. 1535-0092

SLGSafe® APPLICATION FOR INTERNET ACCESS
U.S. TREASURY SECURITIES
STATE AND LOCAL GOVERNMENT SERIES

SLGSafe is a secure electronic commerce Internet site designed by the Bureau of the Public Debt 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 Public Debt, 200 Third Street, P.O. Box 396, Parkersburg, WV 26106-0396. You may also complete a SLGSafe
Template Worksheet and mail it with your Application. The completed worksheet will be used to create a SLGSafe template 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
Region (optional)

–

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 PUBLIC DEBT
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 Public Debt,
Forms Management Officer, Parkersburg, WV 26106-1328.

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