We are writing to tell [1] that the Internal Revenue Service (IRS) has asked to take
money from [2][3] because [4] them money. The IRS calls this action a Notice of Levy.
What You Need To Do
To help decide the correct amount of money to send the IRS, [5] [6] complete the enclosed
Exemption Statement and return it within 10 days from the date [7] this letter. [8].
Send the completed statement to:
[9]
If we do not receive the completed statement within the 10-day period, IRS will only
allow an exemption amount of $[10].
If [11] more information or [12] any questions, please contact [13] local IRS office.
Enclosure:
Exemption Statement
Fill-ins:
[1]
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Choice 1 -
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you
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Choice 2 -
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Name of beneficiary, in format: John Smith
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[2]
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Choice 1 -
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your
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Choice 2 -
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his
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Choice 3 -
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her
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[3]
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Choice 1 -
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Social Security payments
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Choice 2 -
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Black Lung payments
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Choice 3 -
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Social Security and Black Lung payments
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[4]
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Choice 1 -
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you owe
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Choice 2 -
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he owes
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Choice 3 -
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she owes
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[5]
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Choice 1 -
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you
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Choice 2 -
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Mr. plus Last Name of Beneficiary
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Choice 3 -
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Ms. plus Last Name of Beneficiary
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[6]
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Choice 1 -
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need to
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Choice 2 -
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needs to
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[7]
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Choice 1 -
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you receive
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Choice 2 -
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he receives
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Choice 3 -
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she receives
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[8]
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Choice 1 -
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Keep Part 2 for your records
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Choice 2 -
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Keep Part 2 for his records
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Choice 3 -
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Keep Part 2 for her records
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Choice 4 -
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null
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[9]
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PSC return address
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[10]
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current $$ amount for married filing separate
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[11]
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Choice 1 -
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you need
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Choice 2 -
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he needs
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Choice 3 -
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she needs
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[12]
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Choice 1 -
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have
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Choice 2 -
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has
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[13]
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Choice 1 -
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your
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Choice 2 -
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his
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Choice 3 -
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her
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XXX-XX-XXXX Page 2 of 2
STATEMENT OF EXEMPTIONS AND FILING STATUS
(TO BE COMPLETED BY TAXPAYER)
My filing status for my Income Tax Return is (check one):
Single
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Married Filing a Joint Return
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Head of Household
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Qualifying Widow(er)
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Married Filing a Separate Return
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I also claim additional exemption(s) for:
I certify that I can claim the people named below as personal exemptions on my income
tax return and that none are claimed on another Notice of Levy. No one I have listed
is my minor child to whom (as required by court or administrative order) I make support
payments that are already exempt from levy. I understand the information I have provided
may be verified by the Internal Revenue Service. Under penalties of perjury, I declare
that this statement of exemptions and filing status is true.
Name of dependents claimed as exemptions:
Name (Last, first, middle initial)
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Relationship (husband, wife, son,etc.)
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Social Security Number |
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Taxpayer's Signature Date