Form FS Form 4144 FS Form 4144 Subscription for Purchase and Issue of U.S. Treasury Sec

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

OMB No. 1530-0065

See Instructions on Back

Pursuant to the provisions of 31 CFR Part 344, the undersigned hereby requests the early redemption of State and Local Government
Series Securities. The undersigned certifies that this request complies with the requirements in 31 CFR Part 344.

SUBSCRIPTION STATUS: (Check one)

NEW

CHANGE

REQUESTED REDEMPTION DATE: $

ISSUE DATE:

MM

DD

YY

ISSUER:
Underlying Bond Issue:
Taxpayer Identification Number and Suffix:
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:
Telephone: Fax:

(Organization)
(Name and Title)
(Signature)

(Date)

(Telephone)

RESET

FOR BUREAU OF THE FISCAL SERVICE USE ONLY
Rate Table Date:

FS Form 4144

Processed by:

Department of the Treasury | Bureau of the Fiscal Service

Verified by:

Revised February 2016

U.S. TREASURY SECURITIES
STATE AND LOCAL GOVERNMENT SERIES
TIME DEPOSIT

Instructions

Bureau of the Fiscal Service
Special Investments Branch
200 Third Street
P.O. Box 396
Parkersburg, WV 26102-0396

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

For information on subscribing electronically, visit our website listed above.
Subscription Status:
• C
 heck “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 Fiscal Service 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. Fiscal Service will not accept subscriptions
received more than 60 days prior to the issue date.
• C
 heck “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 Fiscal Service 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 Fiscal Service, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND
completed form to this address; send to the correct address shown in the instructions.

FS Form 4144

Department of the Treasury | Bureau of the Fiscal Service

Revised February 2016