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BE IT ACKNOWLEDEGED, that I John Henry; Doe of City Here, Minnesota, the undersigned
deponent, being of legal age, does hereby depose and say under oath as follows:

1.) Deponent is not “liable” for the $1234.56 as shown and inferred in said Notice, and no such
amount “is owed” by John Henry; Doe as claimed and/or inferred in the Notice of Levy
received by COMPANY NAME HERE, and which was dated September 2, 2004.
2.) John Henry; Doe never received a “Notice and Demand” for payment of any alleged income,
or 1040 taxes, due for the year in question
3.) I, John Henry; Doe, never received a “Final Notice of Intent to Levy”
4.) I, John Henry; Doe, have no knowledge of a “Lien of Judgment” as required by law in this
5.) I, John Henry; Doe, have no knowledge of a “Writ of Execution” as required by law in this
6.) I, John Henry; Doe, have no knowledge of a “Notice of Seizure” as required by law in this
7.) No law “requires” COMPANY NAME HERE, to turn over any funds pursuant to, said
“Notice of Levy” as claimed and inferred in said Notice without a proper Lien of Judgment,
Writ of Execution, and Notice of Seizure commanding them to do so.
8.) Revenue Officer, Peggy Koschak who sent out said Notice, has no Delegation of Authority
from the Commissioner to send such a Notice to the COMPANY NAME HERE. to seek to
collect income taxes from deponent by distraint, and thus he had no authority to do so.
And I affirm that the foregoing is true, except as to statements made upon information and belief,
and as to those I believe them to be true.
Witness my hand under the penalties of perjury this day ____ of ______, 2004.

John Henry; Doe
c/o 1234 Minnesota St.
City, Minnesota state
Zip Exempt: DMM 122.32
State of Minnesota )
) ss
County of )

On this ___ day of ________________ 2004 before me, ______________________________

personally appeared, personally known to me (or proved to me on the basis of satisfactory evidence) to be
the person whose name is subscribed to the within instrument and acknowledged to me that he executed
the same in his authorized capacity, and that by his signature on the instrument the person, or the entity
upon behalf of which the WITNESS my hand and official seal.

NOTARY: ______________________________________ SEAL:

MY COMMISSION EXPIRES: _____________________