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519

Verification for Application

[date]

District Director

Internal Revenue Service

P.O. Box ________

City, State Zip Code

ATTN: Disclosure Officer

RE: Tax Disclosure Pursuant to 26 U.S.C. § 6103(i)(2)

(NAME OF CASE and NUMBER)

Dear Sir:

Pursuant to 26 U.S.C. § 6103(i)(2), the Department of Justice requests the Internal Revenue Service to furnish return information, other than taxpayer return information, for the taxable period(s) (STATE YEARS FOR WHICH DISCLOSURE IS SOUGHT) _________________________________ regarding:

NAME:

ADDRESS:

SOCIAL SECURITY NUMBER:

EMPLOYER IDENTIFICATION NUMBER:

The subject(s) of this request is/are the subject(s) of an investigation/indictment regarding possible violations of ____ U.S.C. _________.

Involved in this investigation/prosecution (STATE FACTS)

____________________________________________________________

___________________________________________________________.

Disclosure of the requested return information is or may be relevant to the investigation/indictment in establishing (STATE REASONS FOR RELEVANCY) _______________________________

____________________________________________________________.

Access to the information will be limited to: (STATE NAMES, TITLES AND ADDRESSES OF ATTORNEYS WORKING ON THE INVESTIGATION OR PROSECUTION):

NAME:

TITLE:

AGENCY:

or such other officers and employees of a Federal agency as shall be specifically assigned to participate in the investigation, preparation for trial, or trial, of this matter. 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.

At this time it is authorized that the disclosed material will be used (STATE INTENDED USE, i.e., WHETHER THE MATERIAL IS SOUGHT SOLELY FOR INVESTIGATIVE PURPOSES AT THE TIME OF THE REQUEST OR WHETHER THE REQUESTER CURRENTLY ANTICIPATES USING THE INFORMATION IN A JUDICIAL PROCEEDING AND AN ESTIMATED TIME TABLE).

Therefore, disclosure is required on or before (DATE).

Sincerely,

(Name of United States Attorney)
UNITED STATES ATTORNEY

By:

(Name of Assistant)
Assistant United States Attorney