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26 U.S.C. § 7201
Sole Proprietorship or Partnership - Excise Tax Return
Attempt to Evade and Defeat Excise Tax

IN THE DISTRICT COURT OF THE UNITED STATES

FOR THE _____________ DISTRICT OF ____________

UNITED STATES OF AMERICA

    v.

_______________________

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No. __________________
26 U.S.C., § 7201

The grand jury charges:

That on or about the ________ day of _________________, 19___, in the ________________ District of __________________, [Defendant's Name],1 a resident of [City], [State], who conducted a retail2 business as a [Sole Proprietorship or Partnership] under the name and style of _______________, with its principal place of business in [City], [State], did willfully attempt to evade and defeat a large part of the retail dealer's3 excise tax on [Article], imposed by Section _______________ of the Internal Revenue Code (Title 26), due and owing to the United States of America for the quarter ending4 ____________, 19___, by preparing and causing to be prepared, and by signing and causing to be signed,5 a false and fraudulent Quarterly Federal Excise Tax Return,6 which was filed with the Internal Revenue Service on behalf of said retail2 business, wherein it was stated that the excise tax due and owing to the United States of America by reason of the retail2 sale of [Article] for said quarter4 was the sum of $__________, whereas, as he [she] [it] then and there well knew and believed, there was due and owing to the United States of America for the said quarter,4 retail dealer's3 excise tax in the sum of $_________.

In violation of Title 26, United States Code, Section 7201.

A True Bill.

_________________________
Foreperson

_________________________
United States Attorney


NOTES

1. If a corporation is named as the defendant, substitute the name of the corporation.

2. Designate appropriate business, e.g., manufacturing.

3. For other excise taxes, see 26 U.S.C., § 4041, et seq.

4. Designate appropriate period.

5. If venue is to be placed in judicial district in which the return was filed, modify this form in accordance with language at Forms - 3 and related Footnote 2. If venue is based on mailing, substitute "by mailing and causing to be mailed".

6. Designate appropriate IRS form.


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