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~hi~ere~andpena~yasshownbe~w.

________________________________

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

Penalty (dollars)

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).

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

~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 (dollars)

Accrued Interest
(dollars)

Accrued Late Payment

Penaltv (dollars)

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).

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 (dollars)

Accrued Interest
(dollars)

Accrued Late Payment

Penalty (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

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 (dollars)

Accrued Interest
(dollars)

Accrued Late Payment

Penaltv (dollars)

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).

Signature

Subscribed and Sworn to Before Me On

Title
Month

Day

Year
Address

10 Number

Telephone Number