FREEDOM OF INFORMATION ACT REQUEST

CERTIFIED R ETURN RECEIPT #:___________________________

TO:
Attorney General John Ashcroft FROM: __________________________
United States Justice Department __________________________
10th and Constitution Avenue, NW __________________________
Washington, DC 20224 __________________________

Former Account #: _______-_____-________

Dear Mr. Ashcroft:

This is a request under the Freedom of Information Act, 5 U.S.C. 552, or regulations thereunder. This is my firm
promise to pay fees and costs for locating and duplicating the records requested below, ultimately determined
in accordance with 26 CFR 601.702(f). If some of this request is exempt from release, please furnish me with
portions reasonablely segregable. I am waiving personal inspection of the requested records. I am attesting
under the penalty of perjury, under the laws of the united States of America, that I am a category E requester.
PLEASE EXPEDITE THIS REQUEST.

This request pertains to the years: _____________________________________________________

BACKGROUND: See Exhibit “A” , Treasury Order No. 24 (Rev1)

1. Please send Requester a copy of the notice sent by the District Director ordering this
Requester to keep books and records, what types of books and records, how the records
are to be kept, and for what specific type of tax, which pertains to the above mentioned
account number and individual.

Dated:___________________

Respectfully,

/S/_______________________________, Requester

I understand the penalties provided in 5 U.S.C. 552a(i)(3) for requesting or obtaining access to records under
false pretenses.

/S/_______________________________, Requester

SUBSCRIBED AND AFFIRMED:

On this _____day of ______________, 20_____, personally appeared _____________________, known

to me , OR proved to me on the basis of satisfactory evidence to be the one whose name is subscribed to this
instrument.
Witness my hand and of ficial seal.
/S/__________________________
Notary State of _______________
My Commission Expires:_____________

Known to Me___Produced ID:_____________________

(Pg. 1of2)
Notice: Copies of this letter have been sent to the following agencies and representatives:

MELANIE ANN PUSTAY

Deputy Director
Office of Information & Privacy
Suite 570, Flag Bldg.
Department of Justice
Washington, DC 20530-0001

Director, Office of Disclosure

Internal Revenue Service
1111 Constitution Ave., NW
Washington, DC 20224

Assistant Commissioner (International)

950 L’Enfant Plaza SW
Fourth Floor
Washington DC 20024

Privacy Act Request

Bureau of Al cohol, Tobacco, and Firearms
Room 8290
650 Massachusetts Ave., NW
Washington DC 20226

Att: Disclosure Officer Room 810

Internal Revenue Service Foreign Operations District FOD:5
PO Box 384
Washington DC 20044

Freedom of Information and Privacy Act Unit, Tax Division

US Department of Justice
ATTN: Ms. Ruby McCoy
PO Box 227, Ben Franklin Sta.
Washington DC 20044

(Pg. 2 of 2)