1. I am a duly commissioned ________________________________ in the ______________________ Division of the Office of the District Director of the Internal Revenue Service in ____________________ , _________________________________.
2. In that capacity, I am conducting an investigation to ascertain the correctness of the U.S. ___________________________ Tax Return (Form ________) of _____________________________________________ for the _________ tax year.

3. In furtherance of the above-described investigation and in accordance with 26 U.S.C. § 7602, on ___________________________, I issued a summons to ___________________________________________ requiring him to give testimony and produce for examination certain books, records, papers, and other data relating to my investigation. A true and correct copy of the summons I issued is attached hereto as Exhibit A.

4. __________________________________ executed the U.S. ________________________ Tax Return (Form _______ of __________________________________________ for the ________ tax year in his capacity as _______________ of that entity.

5. On ________________________________ in accordance with 26 U.S.C. �, I served the Internal Revenue Service summons described in paragraph 3, above, on the respondent, ________________________________, by handing an attested copy of the summons to him, as evidenced by the certificate of service located on the reverse side of the summons. See Exhibit A.

6. ____________________________________ failed to appear and provide the information sought, on _______________________________________, as directed by the summons.

7. [On _______________________, ______________________ appeared at my office and indicated he was prepared to comply with the summons I issued to him on _________________________________. While Mr. ____________ allowed me to review a number of documents, he refused to permit me to copy any of the documents I reviewed. In addition, he refused to permit me to review a number of the documents described in the summons. I believe the respondent has satisfied his obligation with respect to the items identified in paragraph numbers ______ and ________ Exhibit A attached to the subject summons. He has failed or refused, however, to permit me to inspect and copy the items identified in paragraph numbers _________ and __________. Further, he has failed or refused to testify as required by the summons.]

   7. None of the information or documents identified in paragraph numbers ______________________ of Exhibit A attached to the subject summons are already in the possession of the Internal Revenue Service.

8. All of the administrative steps required by the Internal Revenue Code for the proper issuance and service of a summons have been taken with respect to the above-described summons.

9. No referral to the Department of Justice, as contemplated by 26 U.S.C. �(c), has been made with respect to _____________________________________________________________ for ________ the tax year.

10. The information and documents sought by the summons are necessary to assist in the above-described examination.

______________________________________

Internal Revenue Service