TN 33 (02-98)

NL 00703.752 Imposition of Levy Against Part of Monthly Benefit Payment

Document Identifier: E3752

Exhibit Letter

We are writing to tell [1] that the Internal Revenue Service (IRS) will take part of [2][3] because [4] them money. The IRS calls this action a Notice of Levy.

What We Will Take Out

The IRS will take $[5] from each monthly payment to collect what [6]. [7] will receive a payment for $[8] each month beginning with the payment [9] would receive around [10].

If [11] more information or [12] any questions, please contact [13] local IRS office.

Fill-ins:

[1]

Choice 1 -

you

 

Choice 2 -

Name of beneficiary, in format: Mr. Smith

[2]

Choice 1 -

your

 

Choice 2 -

his

 

Choice 3 -

her

[3]

Choice 1 -

Social Security benefits

[4]

Choice 1 -

you owe

 

Choice 2 -

he owes

 

Choice 3 -

she owes

[5]

$$ amount withheld each month

[6]

Choice 1 -

you owe

 

Choice 2 -

Name of beneficiary, in format: Mr. Smith owes

[7]

Choice 1 -

You

 

Choice 2 -

He

 

Choice 3 -

She

[8]

$$ amount of monthly benefit after withholding

[9]

Choice 1 -

you

 

Choice 2 -

he

 

Choice 3 -

she

[10]

MM/DD/YYYY

[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