Form 1000
(Rev. September 2016)
Department of the Treasury
Internal Revenue Service
Ownership Certificate
Information about Form 1000 is at www.irs.gov/uac/about-form-1000.
OMB No. 1545-0054
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 U.S. identifying number Name of withholding agent
Employer identification number
Address of owner (number and street, city or town, state or province, country, ZIP or
foreign postal code)
U.S. address of withholding agent (number and street, city or town, state, and
ZIP code)
I CERTIFY that to the best of my knowledge and belief, the
information entered on this form is correct.
Name of bond and date of issue
Date interest due Date interest paid
Signature of owner, fiduciary, trustee, or agent
Address of fiduciary, trustee, or agent (number and street, city or
town, state or province, ZIP or foreign postal code)
If an estate or trust, enter name
Classes of Bond Owners
Gross Amount
of Interest Paid
Tax
Assumed
(2%)
1
(a) Individual, estate, or trust, whose taxable income
exceeds the deductions for exemptions; or (b)
partnership . . . . . . . . . . .
$ $
2
Individual, estate, or trust, whose taxable income
does not exceed the deduction for exemptions . .
$
No tax paid
by corporation
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 17097D
Form 1000 (Rev. 9-2016)
dd mmm yyyy
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Form 1000 (Rev. 9-2016)
Page 2
Instructions for Owner, Fiduciary, Trustee, or
Agent
Use a separate Form 1000 for each issue of bonds. If amended
certificates are necessary, forward them to the withholding agent by
February 1 of the following year.
Where 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.
Instructions for Withholding Agents
Use Form 1042 to summarize Forms 1000. Do not send Form 1000
to the IRS. 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
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: Recordkeeping, 3 hr., 6 min.; Learning about the law or
the form, 6 min.; Preparing the form, 9 min.
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 send us comments from
www.irs.gov/formspubs. Click on “More Information” and then on
“Give us feedback.” You can write to the Internal Revenue Service,
Tax Forms and Publications, 1111 Constitution Ave. NW, IR-6526,
Washington, DC 20224. Do not send this form to this address.
Instead, see Where to file, earlier.
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