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FREEDOM OF INFORMATION ACT REQUEST

CERTIFIED R ETURN RECEIPT #:_____________________________


TO:
District Director FROM: __________________________
Internal Revenue Service __________________________
_________________________ __________________________
_________________________ __________________________

Former Account #: _______-_____-________


Dear Director:

This is a request under the Freedom of Information Act, 5 USC 552, or regulations th ereunder. This is my firm
promise to pay fees and costs for locating and duplicating the records requested below, ultimately determined
in accordance with 26 CFR 601.702(f ).

If some of this request is exempt from release, please furnish me with portions reasonablely segregable. I am
waiving personal inspection of the requested records.

I am attesting under the penalty of perjury, under the laws of the united States of America, that I am a category
E requester. PLEASE EXPEDITE THIS REQUEST.

This request pertains to the years: _____________________________________________________

1. Please send me a copy of the determination that this Requester failed to file a tax return for the
year(s) above stated.
2. Please send this Requester a copy of the document, which discloses the identification number of
the audit group and branch to which Requester’s case has been assigned.
3. Please send this Requester a copy of the document, which discloses the identity of the tax for
which you assert that this Requester failed to file a form.
4. Please send this Requester a copy of the form, which you believe is the form, which this Requester
failed to file.
5. Please send this Requester a copy of the document which, indicated a search was made for the
subject form.
6. Please send this Requester a copy of the 6001 notice requiring this Requester to file a return.

Dated:___________________
Respectfully Submitted,

/S/_______________________________, Requester
I understand the penalties provided in 5 USC 552a(i)(3) for requesting or obtaining access to records under false
pretenses.

/S/_______________________________, Requester

SUBSCRIBED AND AFFIRMED:


On this _____day of ______________, 20_____, personally appeared _____________________, known
to me , OR proved to me on the basis of satisfactory evidence to be the one whose name is subscribed to this
instrument.
Witness my hand and of ficial seal.

/s/__________________________

Notary State of _______________


My Commission Expires:_____________
Known to Me___Produced ID:_____________________