Form For m 4490 (Rev. 2-200 2-2005) 5)
Proo Pr ooff of Cl Clai aim m fo for r Inte In tern rnal al Re Reve venu nue e Ta Taxe xes s I n the for the
Court _
In the Matt tte er of:
Tax Ta xpa payer yer's 's Ide Iden nti tify fyiing
Numb Nu mber: er:
Social Security Number
The undersig undersigned ned offi officer cer of the Inte Internal Rev Revenu enue e Ser Servic vice, e, a duly duly author authorize ized d age agent nt of the the Uni United ted Sta States tes in 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 _________ _________ _ ___ _____ __ __
_
re~andpena~yasshownbe~w. ~w~hi~e
2. Thi This s deb debtt is for taxes taxes due under under the Int Intern ernal al Rev Revenu enue e law laws s of the Uni United ted Sta States tes as fol follows: Kind o f Tax and Period
Unpaid As Assessed o llar llar s) s) Balance Balanc e (d o
Accrued Interest (dollar s s )
Accrued LatePayment s ) Penalty (dolla r rs)
Total
Date Ta Tax Lien Aros Arose e
3. No part of this this deb debtt has been paid, paid, and it is now now due and pay payabl able e to the the Uni United ted Sta States tes Tre Treasu asury ry at the the Offi Office ce of Interna Internall Rev Revenu enue e Service; 4. Except Except for the statuto statutory ry ta tax x lie liens ns that aro arose se on the above above dat dates es,, the United United Sta States tes doe does s not hold hold,, to the the deponen deponent's t's kno knowle wledge dge or belief,, any securit belief security y for this debt; debt; 5. No note or other other negoti negotiable able ins insttrum rument ent has been been receive received d for th this debt or any part of it, it, nor has any any judgmen judgmentt bee been n ren render dered ed wit with h respec res pectt to this debt; debt; and 6. Thi This s deb debtt has priori priority ty and must be paid paid in ful ulll in adva advance nce of distr distriibut 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.. Sect Section ion 3713 3713(a) (a).. Any exec executor utor,, admin adminiistrator strator,, or other other per person son who fails fails to pay the claims claims of the the Uni United ted Sta Stattes in accord acc ordanc ance e wit with h its prior priority ity may become become per person sonal allly li liab able le for this this debt debt un unde derr 31 U. U.S.C. Section 3713( 3713(b) b)..
Subscr Sub scribe ibed d
Signatur gnature e
and Sworn Sworn to Before Before Me On
Title Titl e 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 ________________________________
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 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 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 creditors 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). (Notarize or witness if court requires)
Subscribed and Sworn to Before Me On
Part 2 - After acknowledgement by receiving officials, please return to the Internal Revenue Service
.
Signature
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 ~ecurity 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 _____________ __ ______________ _ ___
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 (dol l ars)
Accrued Interest (do l la rs )
Accrued Late Payment Penaltv (do ll ars)
Total
Date Tax LienArose
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 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 creditors 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 Before 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 Period
Unpaid Assessed Balance (d o ll a rs )
Accrued Interest ( d ol l ars)
Accrued Late Payment Penalty ( do llar 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 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 creditors 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). (Notar iz e or w itness if court requires)
Subscribed and Sworn to Before Me On
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 ______ __ _________________________
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 Period
Unpaid Assessed Balance (dol l ars)
Accrued Interest ( do l la r s )
Accrued Late Payment Penaltv (dol l ars)
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 Treasury 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 creditors 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
Signature
and Sworn to Before Me On
Title Month
Day
Year Address
10
Number
Telephone Number
