MONEY ORDER RECEIPT

Registration Number: _________________________

7007 0000 0001 0000 1234
28 MAY 2010
Date Issued: _______________________
$572.00
Amount: ________________________________________________________
Payee:

_______________________________________________
UNITED STATES TREASURY
_______________________________________________
1500 PENNSYLVANIA AVENUE NW
_______________________________________________
WASHINGTON, DC 20220
_______________________________________________

Account: ________________________
123456789

Payor:

_______________________________________________
JOHN H DOE
_______________________________________________
1234 MAIN ST
_______________________________________________
HUNTINGTON BEACH, CA 92648
_______________________________________________

Memo: _________________________________________________________
ACCOUNT # 100020770

--------------------------------------------------------------------------------------------------------------------------------------------------28 MAY 2010

Date: ______________________

MONEY ORDER
0000 0001 0000 1234
Tracking No.: 7007
___________________________

Pay to the order of: ____________________________________________________________

for $___________________
UNITED STATES TREASURY
572.00
Pay: ______________________________________________________________________________________
DOLLARS
FIVE-HUNDRED SEVENTY-TWO AND 00/100
Memo: ____________________________________________
ACCOUNT # 100020770
JOHN H DOE
1234 CREDITOR STREET
HUNTINGTON BEACH, CA 92648
123456789
Account No.: ______________________

By: ________________________________________
Authorized Representative
Processor:

IRS Technical Support Division

c/o The Treasury UCC Contract Trust Department of the IRS
Department of the Treasury
1500 Pennsylvania Avenue, NW
Washington, D.C. 20220