Please fill out the following Affidavit and return by certified mail to __________________________ within 15 days. You may fill out only those items that you are prepared to swear to or affirm. You may refuse certain items by drawing a line through the items and initialing those items in the margin.


I am an authorized Internal Revenue Service agent and I hereby swear to, or affirm, the following statements:

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

income(excise) tax.

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 Title___________________________________________________
Agent's I.R.S. Division Name_____________________________________
Witness Signature and Printed Name_____________________________________________