I am a revenue officer employed in the Collection Division of the
Office of the District Director, Internal Revenue Service, _____________,
______________, I have the duty and authority to collect federal taxes by seizure
and sale under the provisions of 26 U.S.C. sec. 6331.
From my personal examination of the Internal Revenue Service Collection
File with respect to _________________________ (hereafter referred to as the
taxpayer), I have ascertained that assessments of federal [income or employment]
taxes have been made for the following periods, in the following amounts, and
that notices and demands therefor were made to the taxpayer on the dates
indicated:
[On _________, ____, while at the taxpayer's business premises located at
_________________, ______________, ______________, I observed property including,
but not limited to, desks, chairs, filing cabinets, display cases, computer,
engraving machines and inventory of trophy plate materials. ______________,
President, stated that the taxpayer owned the aforementioned property. Based
upon the nature and type of business, it is believed and anticipated that
additional property in the form of cash, checks, credit card slips/drafts and
accounts receivable will be on the premises.]
On __________, ____, I asked _______________ for his consent to enter the
above premises for the purpose of seizing the taxpayer's property, but said
request was refused. I informed the taxpayer that I would immediately make a
request to the United States District Court for an order of entry on the premises
to effect levy.
With respect to the above noted assessments, notice in conformity with the
requirements of 26 U.S.C. sec. 6331(d) has been met as follows:
Assessment for Method of Delivery Date of Delivery
Period Ending of Notice of Notice
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Certified Mail
Certified Mail
Certified Mail
Certified Mail
The taxpayer's neglect or refusal to pay the aforementioned outstanding
federal tax liabilities in full has continued to the date of this declaration,
and there is now due and owing with respect thereto, a total of __________ plus
statutory additions.
I declare under penalty of perjury that the foregoing is true and
correct.