TREASURY DEPARTMENT This form will not be accepted unless all information called for is furnished. STATEMENT OF INCOME RECEIVED BY NONRESIDENT ALIEN FROM SOURCES WITHIN UNITED STATES PERSONAL EXEMPTION CLAIMED. To be died with withholding sent by nonresident allen individual owning bonds of a domestle corperation which contain a ten-free covenact disum. The st tion of this oartiste does not relieve the bond owner from filing ownership certificates required by the regulations. NAMES MUST BE PRINTED OR WRITTEN PLAINLY. Citizens or subjects of the countries enumerated in Class (a) of Article 307, Regulations 43, as amended, will be allowed for the purpose of the normal tax the following credit: In the eam of a single person, a personal exemption of $1,000, or in the case of the head of a family or a married person living with husband or with, a personal exemption of $2,000. A husband and wile living together shall receive but one personal exemption of $2,000 against their aggregate net income and in deliver make separate returns, the personal exemption of $2,000 may be taken by either or divided between them; $200 for each person (other than husband or wise) dependent upon and renelving his chief support from the taxpayer, if such dependent person is under eighton years of age or is Inoupable of self-support because mentally or physically detective. Citizens or subjects of the countries enumerated in Class (b) of Article 307 will be allowed the benefit of the personal exemption but no credit for dependents. Citlu of subject of the countries enumerated in Class (c) of Article 307 will not be permitted to claim the benefit of personal exemption or credit for dependents and shoul Lerature not use this form. TO BE FILLED IN BY WITHHOLDING AGENT. District in which return Form 1013 is filed. Amount of tax required to be withheld at source as shown by Form 1013, for 1919, $. To be reduced on account of personal exemption claimed as indicated by this certificate, the items appearing on the following monthly returns, Form 1012: Form 1001-B In case a nonresident alien is entitled to personal exemption and credit for dependents in accordance with paragraphs (c) and (d), Section 216 of the Revenue Act of 1918 and Article 307, Regulations 45, as amended (see page 7), and his gross income from sources in the United States, (including bond interest) does not exceed his personal exemption and credit for dependents, a certificate on Form 1001-B should be executed and filed with the withholding agent, if any part of the gross income is derived from interest on bonds of a domestic corporation, which contain a "tax-free" covenant clause. The execution of this certificate does not relieve the bond owner from filing ownership certificates required by the regulations. All certificates Form 1001-B may be filed with the withholding agent at the end of the calendar year, but not later than February 1 of the succeeding year, and all such certificates should be attached to the annual list return Form 1013. The amount of tax due from the withholding agent as shown on Form 1013 may be reduced by 2 per centum of the aggregate amount of the interest payments made to the nonresident alien upon "tax-free" covenant bonds during the calendar year and the amount of tax represented by the certificates, payment of which was assumed on the monthly list return Form 1012, will not be included in the assessment against the withholding agent. In case tax in excess of a nonresident alien's tax liability has been withheld from interest upon bonds which do not contain a "tax-free" covenant clause, the nonresident alien should file or cause to be filed with the collector of internal revenue, a return of his gross income from all sources within the United States, accompanied by a claim for refund on Form 46. Form 1058. Revised February, 1919. SUBSTITUTE CERTIFICATE-TAX NOT TO BE PAID AT SOURCE INTEREST ON BONDS AND OTHER SIMILAR OBLIGATIONS OF DOMESTIC AND RESIDENT CORPORATIONS DEBTOR ORGANIZATION I certify that the owner of the bonds from which were detached the accompanying Interest coupons has filed a certificate of ownership, Form 1001, duly executed as required by Treasury Regulations, and that under the provisions of the Income Tax law, said interest is exempt from the withholding of tax at the source, or that exemption was claimed as stated herein; and I hereby promise to forward the said certificate to the Commissioner of Internal Revenue at. Washington, D. C. Name of bank or collecting agent... Name, address, and This certificate should be attached to interest coupons by the collecting agent as a substitute for the owner's certificate Form 1001. Form 1058 Substitute Certificate Tax Not to be Paid at Source Resident collecting agents and responsible banks and bankers receiving for collection interest coupons from (a) bonds and other similar obligations of domestic and resident corporations not containing a "tax-free" covenant owned by (1) citizens or residents (individuals and fiduciaries); (2) resident partnerships; (3) domestic and resident corporations; (b) bonds or other similar obligations containing a “tax-free” covenant owned by (1) citizens and residents (individuals and fiduciaries), claiming exemption; (2) domestic and resident corporations, with ownership certificates Form 1001 attached, may detach the original certificates and forward them directly to the Commissioner of Internal Revenue, providing such collecting agent shall substitute for such certificates, its own certificates on Form 1058, keeping a complete record of each transaction, showing the serial number of each item received; date received; name and address of person from whom received; name of debtor corporation; class of bonds from which coupons were cut and the face amount of coupons. For the purpose of identification, the substitute certificates should be numbered consecutively, reverting to the numeral 1 at beginning of each calendar year, and corresponding numbers noted on the original certificates of ownership. The use of substitute certificates is not permitted, however, in the case of ownership certificates presented with coupons for collection by nonresident alien individuals, partnerships, or corporations. The original certificates should be endorsed as follows: "Owner's Certificate No..... (Name of bank or collecting agent) (Give date of certificate) 19.... "The counterpart of the within certificate bearing like number was attached to the coupons within mentioned for delivery, to the debtor or withholding agent, by whom the coupons are payable." The debtor corporation or its duly authorized paying agent shall forward all certificates Form 1058 to the Commissioner of Internal Revenue with the monthly list return Form 1096-A. Form 1059. Revised February, 1919. SUBSTITUTE CERTIFICATE-TAX TO BE PAID AT SOURCE INTEREST ON BONDS AND OTHER SIMILAR OBLIGATIONS OF DOMESTIC AND RESIDENT CORPORATIONS DEBTOR ORGANIZATION I certify that the owner of the bonds from which were detached the accompanying interest coupons has filed a certificate of ownership, Form 1000, duly executed as required by Treasury Regulations, and I hereby promise to forward the said certificate to the Commissioner of Internal Revenue at Washington, D. C. Name of bank or Name, address, and |