For m 4490 (Rev. 2-200 2-2005) 5)
Proo rooff of Cla laim im for Interna nternall Revenue Taxes In the for the
Court _
In t he Matt er o f :
Tax Ta xpa payer yer's 's Ide Iden nti tify fyiing
Numb Nu mber: er:
Social Security Number
The undersig undersigned ned off office icerr of the the Inte Inte r nal n al Rev Revenu enue e Ser Servic vice, e, a duly duly author author ized i zed age agent nt of the the Uni United ted Sta States tes in this this behalf, behalf, bei being ng duly dul y swo sworn, rn, dep depose oses s and says that: that: 1.
is justly an and d trul truly ind indebt ebted ed to the the United United State ates s in the amount amount of _________ _________ _ ___ ___ _____ _____ __ __ __ __ _
~w~hi~er ~w~hi~e r e~andpena~yasshownbe~w. e~andpena~yasshownbe~w.
2. This This deb debtt is for for taxes taxes due und unde er r the Int Intern ernal al Rev Revenu enue e law laws s of the the Uni United ted St State ates s as fol fol lows: Kind o f Tax and Period
Unpaid As Assessed (do ollar s) s) Balance (d Balance
Accrued Interest
(dollar s)
Accrued Late Payment Penalty (dolla (dollar r s) s)
Total
Date Ta Tax Lien Aros Arose e
3. No part of this this deb debtt has been pai paid d, and it is now due and payable payable to the the Uni United ted Sta States tes Tre Treasu asury ry at the the Off Office ice of Intern Internal al Rev Revenu enue e Service; 4. Except Except for the statut statutory ory ta tax x liens liens tha thatt aro arose se on the above above dat dates es,, the Uni United ted St State ates s doe does s not hold hold,, to the the deponent deponent's 's kno knowle wledge dge or belief , any security security for this debt; debt; 5. No note or other other negoti negotiable able ins insttrum rument ent has been been rec receiv eived ed for th this debt or any part of it, it , nor nor has any judgm judgment ent bee been n ren render dered ed wit with h respect respe ct to this debt; debt; and 6. This This deb debtt has priori priority ty and must be paid paid in f ull ull in advan advance ce of distr distr ibut bution ion to credi creditor tors s to the extent extent pro provid vided ed by law: law: See 31 U. U.S.C S.C.. Section Section 3713 3713(a) (a).. Any exec executor utor , admini administrator , or other other per person son who fails fails to pay the the claims of the the United United Sta Stattes in accordance accor dance with its prior priority ity may become become perso personal nallly li liab able le for this this debt debt un unde derr 31 U. U.S.C. Section 3713( 3713(b) b)..
Signatur e
Subscrib Su bscribed ed and Sworn to Before Before Me On
Title Titl e Month
Day
Year Address
10
Number
Telephone Number
For m 4490 (Rev. 2-2005)
Proof of Claim for Internal Revenue Taxes In the f o r the
Cour t _
In the Matt er of :
Taxpayer 's
Identifying
Number :
Social Security Number
The undersigned officer of the Internal Revenue Service, a duly authorized agent of the United States in this behalf , being duly sworn, deposes and says that: 1.
is justly and tr uly indebted to the United States in the amount of ________________________________
~wrthi~ere~andpena"yasshownb~ow.
2. This debt is for taxes due under the Internal Revenue laws of the United States as follows: Kind of Tax and Period
Unpaid Assessed Balance (dollars)
Accrued Interest (dollars)
Accrued Late Payment Penaltv (dollars)
3. No par t of this debt has been paid, and it is now due and payable to the United States Treasur y at the Office of Internal Revenue Service; 4. Except for the statutory tax liens that arose on the above dates, the United States does not hold, to the deponent's knowledge or belief, any security for this debt; 5. No note or other negotiable instrument has been received for this debt or any part of it, nor has any judgment been rendered with respect to this debt; and 6. This debt has priority and must be paid in full in advance of distribution to creditor s to the extent provided by law: See 31 U.S.C. Section 3713(a). Any executor, administr ator , or other person who fails to pay the claims of the United States in accordance with its priority may become personally liable for this debt under 31 U.S.C. Section 3713(b). (Notarize or witness if court requires)
Sub scr ibed
and Sworn t o B ef o re Me On
Part 2 - After acknowledgement by receiving of fi cials, please return to the Inter nal Revenue Ser vice
.
Signature
For m 4490 (Rev. 2-2005)
Proof of Claim for Internal Revenue Taxes In the
Cour t
for the
_
In the Matter of:
Taxpayer's
Identifying
Number :
Social ~ecur ity Number
The under s igned officer of the Internal Revenue Ser vice, a duly author i zed agent of the United States in this behalf, being duly swor n, deposes and says that: 1.
is justly and truly indebted to the United States in the amount of _____________ __ ______________ _ ___
wr thi~er e~andpena~yasshownb~ow.
2. This debt is for taxes due under the Internal Revenue laws of the United States as follows: Kind of Tax and Per iod
Unpaid Assessed Balance (dollars)
Accrued Interest (dollar s)
Accrued Late Payment Penaltv (dollars)
Total
Date Tax LienArose
3. No part of this debt has been paid, and it is now due and payable to the United States Tr easur y at the Of f ice of Inter nal Revenue Ser vice; 4. Except for the statutor y tax liens that ar o se on the above dates, the United States does not hold, to the deponent's knowledge or belief , any secur ity for this debt; 5. No note or other negotiable instr ument has been r eceived f or this debt or any par t of it, nor has any judgment been rendered with respect to this debt; and 6. This debt has priority and must be paid in f ull in advance of distribution to cr editors to the extent provided by law: See 31 U.S.C. Section 3713(a). Any executor , administrator, or other person who fails to pay the claims of the United States in accordance with its priority may become personally liable for this debt under 31 U.S.C. Section 3713(b).
Signature
Subscribed and Sworn to Befor e Me On
Title Month
Day
Year Address
10 Number
Telephone Number
Form 4490 (Rev. 2-2005)
Proof of Claim for Internal Revenue Taxes In the for the
Court _
In the Matter of :
Taxpayer's Identifying
Number :
Social Security Number
The undersigned officer of the Internal Revenue Service, a duly authorized agent of the United States in this behalf , being duly sworn, deposes and says that: 1.
~-----------is
justly and truly indebted to the United States in the amount of
________________ _ _____ _ __ _ _
~----~w~hinterestandpenanyasshownb~ow.
2. This debt is for taxes due under the Internal Revenue laws of the United States as follows: Kind of Tax and Per iod
Unpaid Assessed Balance (dollar s)
Accr u ed Inter est (dollars)
Accrued Late Payment Penalty (dollar s)
3. No part of this debt has been paid, and it is now due and payable to the United States Treasury at the Office of Internal Revenue Service; 4. Except for the statutor y tax liens that arose on the above dates, the United States does not hold, to the deponent's knowledge or belief , any secur ity for this debt; 5. No note or other negotiable instr u ment has been received for this debt or any par t of it, nor has any judgment been rendered with respect to this debt; and 6. This debt has priority and must be paid in full in advance of distribution to cr editors to the extent provided by law: See 31 U.S.C. Section 3713(a). Any executor , administrator , or other person who fails to pay the claims of the United States in accordance with its pr iority may become personally liable for this debt under 31 U.S.C. Section 3713(b). (Notar iz e or witness if court requires)
Subscribed and Sworn to Before Me On
For m 4490 (Rev. 2-2005)
Proof of Claim for Internal Revenue Taxes In the
Cour t
f or the
_
In the Matter of :
Taxpayer's Identifying
Number:
Social Security Number
The under signed of ficer of the Inter n al Revenue Ser vice, a duly author i zed agent of the United States in this behalf, being duly swor n , deposes and says that: 1.
is justly and truly indebted to the United States in the amount of ______ __ _________________________
with interest and penalty as shown below.
2. This debt is for taxes due under the Internal Revenue laws of the United States as follows: Kind ofTax and Per iod
Unpaid Assessed Balance (dollars)
Accr ued Interest (dollar s)
Accrued Late Payment Penaltv (dollars)
Total
Date Tax Lien Arose
3. No part of this debt has been paid, and it is now due and payable to the United States Tr easur y at the Of f ice of Inter nal Revenue Service; 4. Except for the statutory tax liens that arose on the above dates, the United States does not hold, to the deponent's knowledge or belief, any secur ity for this debt; 5. No note or other negotiable instrument has been received f or this debt or any par t of it, nor has any judgment been render e d with respect to this debt; and 6. This debt has prior ity and must be paid in full in advance of distr ibution to cr editor s to the extent provided by law: See 31 U.S.C. Section 3713(a). Any executor, administrator, or other person who fails to pay the claims of the United States in accordance with its priority may become personally liable for this debt under 31 U.S.C. Section 3713(b).
Subscribed
Signatur e
and Sworn to Before Me On
Title Month
Day
Year Addr ess
10
Number
Telephone Number
