Assessment Certificate
Summary Record of Assessments

		

Current Assessments

Deficiency and Additional Assessments (Resulting From Regular Audit Examinations)

Total Assessments

Class of Tax

Tax

Penalty

No. of

Items

Tax

Penalty

Interest

No. of

Items

Interest

5. Jeopardy Assessments Against Principal Taxpayers
(Included in the assessments above)

6. Prepared From Accounting Input Reconciliation Sheets	
Date and Number
Date and Number
Through	

Number of principal taxpayers

Total assessed against principal taxpayers

Certification

I certify that the taxes, penalties, and interest of the above classifications, hereby assessed, are specified in supporting records, subject to such correction as subsequent inquiries and determinations in respect thereto may indicate to be proper.

7. Date

8. Signature (For service center/district director of Internal Revenue)

Assessment Officer

Form 23C (Rev. 10-87) Dispose of all prior issues

Cat. No. 16237T

Department of the Treasury – Internal Revenue Service

i

1. Service center

2. Date

3. Prepared by

4. Number

Withheld individual income and FICA																	
Individual income-other																	
Corporation income and excess profits																	
Excise																	
Estate and gitf																	
Tax on carriers and their employees																	
Federal unemployment tax act																	
Total Assessments