FORM OF CERTIFICATE TO BE PRESENTED WITH COUPONS OR INTEREST ORDERS STATING am the owner of $. a citizen or resident of the United States, bonds of the denominations (Describe the particular issue of bonds.) 191 191..., amounting to $. of registered interest. from which were detached the accompanying coupons, due. or upon which there matured.. I {do not} now claim, with respect to the income represented by said interest, the benefit of a deduction of allowed under paragraph C, Section II, of the Federal income-tax law. I, the. CERTIFICATE TO BE FURNISHED BY ORGANIZATIONS NOT SUBJECT TO TAX ON INTEREST .a.. AT SOURCE. of the. (Name of organization.) do solemnly declare that ..bonds of the denomination of $. (Give name of organization.) .each, Nos.. or upon which there matured. from which were detached the accompanying coupons, due. .191...$. interest, and that under the provisions of the income-tax law of October 3, 1913, said interest is exempt from the payment of taxes collectible at the source, which exemption is hereby claimed. FORM OF CERTIFICATE TO BE PRESENTED WITH COUPONS OR INTEREST ORDERS WHEN NOT ACCOMPANIED BY CERTIFICATE OF OWNERS. I, the (Address.) (Official position.) ..of the do solemnly declare that said .has (or have) purchased or accepted for collection the accom $. panying coupons or interest orders amounting to $. of bonds of the. (Name of debtor.) received said coupons or orders for registered interest from (Collecting agency.) .hereby acknowledges responsibility of withholding therefrom the and that no certificate of ownership accompanied said coupons or interest normal income tax of 1 per cent, in accordance with the regulations of the Treasury Department. FORM OF CERTIFICATE TO BE FILLED OUT AND SIGNED BY MEMBERS OF PARTNERSHIPS. The following certificate should be used when coupons or interest orders are presented by citizens or residents of the United States for collection of interest on bonds, or other similar obligations, owned by the partnerships of which they are members: I, .of. ...... a member of the firm or partnership of. and residing at do solemnly (Give full address.) bonds of the denomination of $. declare that the said partnership is the owner of $. of the (Give name of debtor.) known as. (Describe the particular issue of bonds.) 191. 191..., $. ..bonds, from which were detached the accompanying interest Address: .known as FORM OF CERTIFICATE TO BE PRESENTED WITH COUPONS OR INTEREST ORDERS, DETACHED FROM BONDS OR OTHER OBLIGATIONS OWNED BY THOSE WHO ARE BOTH CITIZENS OR SUBJECTS, AND RESIDENTS OF FOREIGN COUNTRIES. I do solemnly declare that I am not a citizen or resident of the United States of America, but a subject (or citizen) of. and that I am the owner of $. bonds of the denomination each, Nos.. (Give name of debtor corporation.) (Describe the particular issue of bonds.) from which were detached the accompanying coupons, due. or upon which there matured.. $. tered interest, and that being a nonresident foreigner, I am exempt from the income tax imposed on such interest by the United States Government under the law enacted October 9, 1913, and that no citizen of the United States, wherever residing, or foreigner residing in the United States, or any of its possessions, has any interest in said bonds, coupons, or interest. Signature of owner of bonds Date. 191. (Give full name.) Address (Give full post office address.) |