Form 1000 Ownership Certificate

2
TLS, have you
transmitted all R
text files for this
cycle update?

Date

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 1000, PAGE 1 of 2
MARGINS: TOP 8mm (2/6"), CENTER SIDES.
PAPER: WHITE, WRITING, SUB. 20.
FLAT SIZE: 203mm (8") x 92mm (3 2/3")
PERFORATE: (NONE)

PRINTS: HEAD TO HEAD
INK: BLACK

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 1000 (Rev. Dec. 2005)
Department of the Treasury
Internal Revenue Service

Action

Signature

O.K. to print
Revised proofs
requested

Ownership Certificate

Date

OMB No. 1545-0054

For Paperwork Reduction Act Notice, see back of form.

To be used by a U.S. citizen, resident individual, fiduciary, partnership, or nonresident partnership all of whose members are citizens or residents, in connection
with interest on bonds of a corporation containing a tax-free covenant and issued before January 1, 1934.
Owner of bonds (Print or type name)
U.S. identifying number
Withholding agent (Print or type name)
Employer identification number

Address of owner (street, city, state, and ZIP code)

I CERTIFY that to the best of my knowledge and belief, the
information entered on this form is correct.

U.S. address of withholding agent (street, city, state, and ZIP code)

Name of bond and date of issue

Date interest due

Date interest paid

Gross Amount of
Interest Paid

Tax Assumed (2%)

$

$

Signature of owner, fiduciary, trustee, or agent

Classes of Bond Owners
Address of fiduciary, trustee, or agent

1 (a) Individual, estate, or trust, whose taxable income
exceeds the deductions
(b) partnership
If an estate or trust, give name here

2

for

exemptions;

or

Individual, estate, or trust, whose taxable income
does not exceed the deduction for exemptions

Note: If amended certificates are necessary, forward them to the withholding agent by February 1 of the following year.

$

No tax paid
by corporation
Cat. No. 17097D

2
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 1000, PAGE 2 OF 2
MARGINS; TOP 13mm (2⁄6 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄2 ") x 279mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 1000 (Rev. 12-05)

Instructions to Owner, Fiduciary, Trustee,
or Agent
How To File. File this form with the withholding agent for
interest payments on bonds that have a tax-free covenant and
that were issued before 1934 by a domestic corporation or a
resident or nonresident foreign corporation.
Use a separate Form 1000 for each issue of bonds.

Instructions to Withholding Agents
Use Form 1042 to summarize Forms 1000. Do not send Form
1000 to the Internal Revenue Service. Keep Form 1000 for at
least 4 years after the end of the last calendar year in which the
income the form applies to is paid.
If a nonresident foreign corporation with a fiscal or paying
agent in the United States issues the obligation, modify Form
1000 to show the name and address of the nonresident debtor
corporation in addition to the name and address of the U.S.
fiscal or paying agent.
Paperwork Reduction Act Notice. We ask for the information
on this form to carry out the Internal Revenue laws of the United

Page

2

States. You are required to give us the information. We need it
to ensure that you are complying with these laws and to allow
us to figure and collect the right amount of tax.
You are not required to provide the information requested on a
form that is subject to the Paperwork Reduction Act unless the
form displays a valid OMB control number. Books or records
relating to a form or its instructions must be retained as long as
their contents may become material in the administration of any
Internal Revenue law. Generally, tax returns and return
information are confidential, as required by Internal Revenue
Code section 6103.
The time needed to complete and file this form will vary
depending on individual circumstances. The estimated average
time is 3 hours and 10 minutes.
If you have comments concerning the accuracy of this time
estimate or suggestions for making this form simpler, we would
be happy to hear from you. You can write to the Internal
Revenue Service, Tax Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6406,
Washington, DC 20224. Do not send this form to this address.
Instead, see How To File on this page.