1040 Pay to the order of: United States Treasury Charge stated sum to: Internal Revenue Service

MONEY ORDER

Credit the Memory of Account Number:

$2,000
NA

00
no cents

XXX-XX-XXX JOHN D.
NA

Two Thousand and

ADAMS
NA

C/O OFFICE OF DIRECTOR- P.O. BOX XXXX

UNITED STATES

NA

ANY TOWN, ANY STATE XXXXX

NA NA

Certified Tender of Payment for value for: John David Adams. Tender at Par as per HJR 192/P.L. 73-10 6/5 1933, UCC 3-311(a)(b), UCC 3 Release of security Interest. This Tender payable by Assignment of Claim in Security Instrument only. NOTE: Not a bank check, for Holding Account only. UCC 1-201(4)(24)(26) (28)(36)(37), UCC 1-104, UCC 3-304 Private between Parties Partial Assignment of Security Interest

Mail your statement/coupon and the original 1040-V to: Internal Revenue Service Submission Processing Center Fresno, California 93888