1) I understand that ________________________ is a citizen of the State
of________________________ and the United States and is not engaged in a
corporate activity and is not liable for the income tax under the corporate
2) _________________________ is liable for the individual income tax, that
is a direct tax on his property, levied without the Apportionment provision
of the U.S. Constitution.
3) I.R.C. section 7608 or section______________ authorize agents with my
title to perform collection actions under Subtitle A and C.
4)I certify that I am duly delegated to issue Notices of Lien and
Levy by Delegation Order Number_________________ from the Secretary of the
5) My delegation order from the Secretary of the U.S. Treasury to perform
collection actions under Title 26 § 6331 of the Internal Revenue Code are
listed in delegation order number(s)___________________________.
6) I am authorized to take collection action against ______________________,
under the authority of the 16th Amendment without the constitutional
requirements of Apportionment. I understand that _________________________
is not operating as a corporate entity and has not received taxable income
under the definition of "income" in the 16th Amendment as stated by U.S.
Supreme Court rulings.
7) The Internal Revenue Service has the lawful authority under subtitle A to
require ______________________________ to file 1040 forms and require them
to include their souces of income as if those sources were "income" defined
by the U.S. Supreme Court.
8) The Internal Revenue Service has the lawful authority to require
___________________________ to file 1040 forms under penalty of perjury for
any and all years in guestion and this would not violate
___________________________ Constitutional protections.
9) I am authorized to make a subsitute return for the 1040 form under I.R.C. section 6020(b).
10) Our lawful authority to impose and individual direct tax without
Apportionment, that makes ___________________________ liable for the
individual income tax, is the Internal Revenue Code, section
____________,Paragraph(s)__________________, and regulation number
___________________, Paragraph ___________________ of the Code of Federal
Regulations, Title 26.
11) This affidavit constitutes my written verification that the assessment
was lawfully made by the agent(s)named:___________________________________.
12) I further certify that the I.R.S. is acting under all lawful and correct
collection procedures in t he demands made on ______________________________
by the I.R.S.
I declare under the penalty of perjury and under the laws of the United States that the foregoing statements are true and correct, except for the statements that I have crossed out and initialed in the margin.
Printed Name of Agent_________________________________________________________
Agent's Employee Number________________________________________
Agent's I.R.S. Division Name_____________________________________
Witness Signature and Printed Name_____________________________________________