MONEY ORDER RECEIPT

Registration Number: _________________________

RR 111 222 333 US
16 JANUARY 2009
Date Issued: _______________________
$25,755.00
Amount: ________________________________________________________
Payee:

_______________________________________________
FRANCHISE TAX BOARD
_______________________________________________
PO BOX 1468
_______________________________________________
SACRAMENTO, CA 95812-1468
_______________________________________________

Account: ________________________
123456789

Payor:

_______________________________________________
JOHN H DOE
_______________________________________________
1212 MAIN STREET UNIT 220
_______________________________________________
HUNTINGTON BEACH, CA 92648
_______________________________________________

Memo: _________________________________________________________
FTB ACCOUNT NO. 100025478

--------------------------------------------------------------------------------------------------------------------------------------------------16 JANUARY 2009

Date: ______________________

MONEY ORDER
Tracking No.: ____________________
RR 111 222 333
US

Pay to the order of: ____________________________________________________________

for $___________________
FRANCHISE TAX BOARD
25,755.00
Pay: ______________________________________________________________________________________
DOLLARS
TWENTY-FIVE THOUSAND SEVEN-HUNDRED FIFTY-FIVE AND 00/100
Memo: ____________________________________________
FTB ACCT NO. 100025478
JOHN H DOE
1212 MAIN STREET UNIT 220
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