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Consistent and in pari materia with Section 3402(n) of the Internal Revenue Code
("IRC"), shown herewith, I hereby certify to being EXEMPT by law from all federal
income tax withholdings because:
A. No liability for income tax has knowingly been incurred by Me under Subtitle A in
the past year or in previous years.
B. No liability for income tax will knowingly be incurred by Me under Subtitle A in the
current year or in future years.
The only statutes which impose a specific liability for federal income taxes imposed by
Subtitle A are those which are found in the provisions applicable to withholding agents,
as itemized in the definition of "Withholding agent" at IRC 7701(a)(16).
VERIFICATION
The Undersigned hereby verifies, under penalty of perjury, under the laws of the
United States of America, without the "United States" (federal government), that the
above statement is true and correct, to the best of My current information, knowledge,
and belief, so help Me God, pursuant to 28 U.S.C. 1746(1).
Signed: _________________________________________________________
(blue ink signature)
Name: ___________________________________________________________
(printed name)
Address: ________________________________________________________
(c/o street, post office box, or general delivery)
County: _________________________________________________________
(name of county, followed by "county")
1
Attachments:
[IRC 3402(n)]
2
amount. D:R:FP:F Tax Related Public Use