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
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