TN 33 (02-98)

NL 00703.748 Exemption From Levy - Exemption Statement

Document Identifier: E3748

A. EXHIBIT LETTER

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]

Choice 1 -

you

 

Choice 2 -

Name of beneficiary, in format: John Smith

[2]

Choice 1 -

your

 

Choice 2 -

his

 

Choice 3 -

her

[3]

Choice 1 -

Social Security payments

 

Choice 2 -

Black Lung payments

 

Choice 3 -

Social Security and Black Lung payments

[4]

Choice 1 -

you owe

 

Choice 2 -

he owes

 

Choice 3 -

she owes

[5]

Choice 1 -

you

 

Choice 2 -

Mr. plus Last Name of Beneficiary

 

Choice 3 -

Ms. plus Last Name of Beneficiary

[6]

Choice 1 -

need to

 

Choice 2 -

needs to

[7]

Choice 1 -

you receive

 

Choice 2 -

he receives

 

Choice 3 -

she receives

[8]

Choice 1 -

Keep Part 2 for your records

 

Choice 2 -

Keep Part 2 for his records

 

Choice 3 -

Keep Part 2 for her records

 

Choice 4 -

null

[9]

PSC return address

[10]

current $$ amount for married filing separate

[11]

Choice 1 -

you need

 

Choice 2 -

he needs

 

Choice 3 -

she needs

[12]

Choice 1 -

have

 

Choice 2 -

has

[13]

Choice 1 -

your

 

Choice 2 -

his

 

Choice 3 -

her

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       Married Filing a Joint Return
      Head of Household       Qualifying Widow(er)
      Married Filing a Separate Return 

I also claim additional exemption(s) for:

      Age 65       Blind

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)
Relationship
(husband, wife, son,etc.)
Social Security Number

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                                                                         

Taxpayer's Signature                       Date


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900703748
NL 00703.748 - Exemption From Levy - Exemption Statement - 05/01/1999
Batch run: 01/27/2009