IRS FORM PROOF OF CLAIM [4490]

Form 4490 Proof of Claim for (Rev. 2-2005) Internal Revenue Taxes In the Court for the _ 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... More

Form 4490 Proof of Claim for (Rev. 2-2005) Internal Revenue Taxes In the Court for the _ 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 Unpaid Assessed Accrued Interest Accrued Late Payment Total Date Tax Lien Arose and Period Balance (dollars) (dollars) 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 t Less