OWNERSHIP CERTIFICATE-TAX TO BE PAID AT SOURCE DEBTOR ORGANIZATION Names must be printed or written plainly. OWNER OF BONDS (Give name in full) [93] I CERTIFY that the owner of the bonds from which the interest entered herein was derived falls within the class of persons or organizations opposite which such interest is entered, and that exemption is not claimed from having the normal tax paid at the source on the amount of interest reported. Signature of owner or agent. This form must be used by debtor organizations to report payments of interest on registered bonds when such payments are not covered by ownership certificates made by owners of bonds. When so used, the form need not be signed, but must bear the name and address of the debtor organization. *Fiduciaries must enter under "Owner of Bonds" the name of estate, trust, or beneficiary on behalf of whom this certificate is made. If bonds are owned jointly, separate forms must be used by each joint owner. † If owner of bonds is unknown, certificate must be made by first bank which will enter amount of interest on OWNERSHIP CERTIFICATE-TAX NOT TO BE PAID AT SOURCE DEBTOR ORGANIZATION Names must be printed or written plainly. Name. Address. [94] I CERTIFY that the owner of the bonds Signature of owner Address of Agent If the interest on bonds containing tax-free-covenant *Fiduciaries must enter under "Owner of Bonds" the name of estate, trust, or beneficiary on behalf of whom exemption is claimed. If bonds are owned jointly, separate forms must be used by each joint owner. Ownership Certificate-DISCLOSING ACTUAL OWNER OF STOCK. (For use of foreign principal individual, firm or organization to be filed with representative in the United States of such foreign principal to disclose actual ownership of stock of domestic corporation.) I (we) hereby declare that I am (we are) the actual owner- of the above described stock or that the record owner of said stock holds it for my (our) account and the actual owner is.. (Name) (Address) That I am (we are) or the actual owner- is (are) non-resident alien- as to the United States; that the record owner of said stock is correctly listed above and that the said record owner is the representative in the United States of the undersigned with respect to said stock; and that all the information given herein is true and correct Date, 19 By (Signature of actual owner, or, if organization, name for which record owner acts.) (If organization, signature of official authorized to sign, and official position.) (Full Post-Office Address of actual owner, or person, firm or corporation for whom or which record owner acts.) |