From:

Name
Address
City, State [Zip]

To:
IRS Technical Support Division
C/o Treasury UCC Contract Trust
Internal Revenue Service
1500 Pennsylvania Avenue, NW
Washington, DC 20220

Date: __________________

To Whom It May Concern:

Enclosed is Case or letter number or name, dated put the date on the notice here. This
has been Accepted for Value and closure and are enclosed within.

This account is now closed, please notify the following that Case or letter number or
name has been settled and this account is closed:

Put the names and addresses as well as any other contact information of the agencies,
agents, or courts here. Include all pertinent addresses including your own in this space.

Thank you,

_____________________________________
Name

Put stamp here

if using UPU