IN THE UNITED STATES DISTRICT COURT FOR THE
_________ DISTRICT OF ___________
UNITED STATES OF AMERICA )
v. ) CRIMINAL NO.
ORDER FOR DISCLOSURE OF
RETURNS AND RETURN INFORMATION
On this _____ day of ______, 19____, comes for the attention of the Court the application of the United States Attorney for the _____________ District of __________ for an ex parte order, pursuant to 26 U.S.C. 6103(i)(5), directing the Internal Revenue Service to disclose returns and return information of:
SOCIAL SECURITY NUMBER:
for taxable period(s) of ____________________________. After examining the application the Court finds:
(1) A federal arrest warrant relating to the commission of the Federal felony offense (s) of (LIST OFFENSE(s) ____________________________________________________________________________ has been issued for the individual named above who is a fugitive from justice.
(2) There is reasonable cause to believe that such return or return information may be relevant in determining the location of such individual.
IT IS THEREFORE ORDERED that the Internal Revenue Service:
(1) disclose such returns and return information of:
SOCIAL SECURITY NUMBER:
for the taxable period(s) ___________________________ as have been filed and are on file with the Internal Revenue Service;
(2) disclose such returns and return information described above as come into the possession of the Internal Revenue Service subsequent to the date of this order, but for not longer than 90 days thereafter;
(3) disclose such returns and return information only to applicant and
and to no other person;
(4) disclose no returns or return information not described above.
It is further ORDERED that applicant and
and any officer or employee of any Federal agency who may be subsequently assigned in this matter shall use the returns and return information disclosed solely in locating the above-named fugitive, and that no disclosure be made to any other person except in accordance with the provision of 26 U.S.C. § 6103.
UNITED STATES DISTRICT JUDGE
I, ________________, being first duly sworn, depose and say that I am an Assistant United States Attorney for the ___________ District of ___________ and that the foregoing Application is made on the basis of information officially furnished and upon the basis that such information is true as I verily believe.
Assistant United States Attorney
Subscribed and sworn to before me this _____ day of _________, 19_____.
My Commission Expires: