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516

Application for Ex Parte Order to Disclose Returns and Return Information

           IN THE UNITED STATES DISTRICT COURT FOR THE
                  _______ DISTRICT OF _________
                        ________ Division

UNITED STATES OF AMERICA         )
                                 )
          v.                     )   GRAND JURY NO.
                                 )
JOHN DOE NO.                     )

              APPLICATION FOR EX PARTE ORDER TO
             DISCLOSE RETURNS AND RETURN INFORMATION

     Comes now the United States of America, through its attorneys
_____________, United States Attorney for the __________ District of
____________, and                , Assistant United States Attorney,
pursuant to 26 U.S.C. 6103(i)(1), and makes application to the Court for an
ex parte order directing the Internal Revenue Service (IRS) to
disclose to applicant (and to others hereinafter named) returns and return
information of:



 NAME:

 ADDRESS:

 SOCIAL SECURITY NO.:



which returns and return information are described as those returns and
return
information for the taxable period(s) of  _________________.

     In support of its application applicant alleges and states the
following:

     (1) There is reasonable cause to believe, based upon information
believed to be reliable, that violations of Title ____ U.S.C. Section
__________
have been committed.

     (2) There is reasonable cause to believe that the above-described
returns and return information are or may be relevant to a matter relating
to the
commission of such acts.

     (3) The returns and return information are sought exclusively for use
in a Federal criminal investigation or proceeding concerning such acts.

     (4) The information sought to be disclosed cannot reasonably be
obtained, under the circumstances, from other sources.

     Applicant further alleges and states that he/she is an Assistant United
States Attorney for the __________ District of ____________ and is
personally and
directly engaged in investigation and preparation for trial of matters
relating
to the enforcement of the above-mentioned violations of Title __ U.S.C.
Sections
_________________ to which the United States is a party.  The information
sought
herein is solely for our use for that purpose.  No disclosure will be made
to any
other person except in accordance with the provisions of 26 U.S.C. 6103 and
26
C.F.R. 301.6103(i)-1.

     This application is authorized by ______________, United States
Attorney.

     Therefore, applicant prays that this Court enter an order, ex
parte, on this application granting disclosure by the Internal
Revenue
Service of the returns and return information specified in this application.

Respectfully submitted,

_______________________
UNITED STATES ATTORNEY


By:  ________________________________
     Assistant United States Attorney