I, _____________, declare as follows:
- I am a revenue officer employed in the Collection Division of the Office of the District Director, Internal Revenue Service, _____________, ______________, I have the duty and authority to collect federal taxes by seizure and sale under the provisions of 26 U.S.C. sec. 6331.
- From my personal examination of the Internal Revenue Service Collection File with respect to _________________________ (hereafter referred to as the taxpayer), I have ascertained that assessments of federal [income or employment] taxes have been made for the following periods, in the following amounts, and that notices and demands therefor were made to the taxpayer on the dates indicated:
- [On _________, ____, while at the taxpayer's business premises located at _________________, ______________, ______________, I observed property including, but not limited to, desks, chairs, filing cabinets, display cases, computer, engraving machines and inventory of trophy plate materials. ______________, President, stated that the taxpayer owned the aforementioned property. Based upon the nature and type of business, it is believed and anticipated that additional property in the form of cash, checks, credit card slips/drafts and accounts receivable will be on the premises.]
- On __________, ____, I asked _______________ for his consent to enter the above premises for the purpose of seizing the taxpayer's property, but said request was refused. I informed the taxpayer that I would immediately make a request to the United States District Court for an order of entry on the premises to effect levy.
- With respect to the above noted assessments, notice in conformity with the requirements of 26 U.S.C. sec. 6331(d) has been met as follows:
Assessment for Period Ending Method of Delivery of Notice Date of Delivery of Notice Certified Mail Certified Mail Certified Mail Certified Mail
- The taxpayer's neglect or refusal to pay the aforementioned outstanding federal tax liabilities in full has continued to the date of this declaration, and there is now due and owing with respect thereto, a total of __________ plus statutory additions.
I declare under penalty of perjury that the foregoing is true and correct.
[Address and Phone No.]
Updated May 13, 2015