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Date ______________

Invoice # JHS1001
Registered Mail # ____________________________

Non-Negotiable Bill of Exchange


Pass Through Account # 123 45 6789
Re:

Non-Negotiable Acceptance of Inconsideration and Request Inconsolation in Accord with UCC


3-419 and HJR-192 of 5 June 1933, and Registered Adjustment of Account:

COLLATERAL: Proposed Individual Income Tax Assessment


Value of Bill:

_________________________________. The Undersigned accepts for value (all


endorsements/considerations front and back and includes those in accord with UCC 3419) as evidence with the herein Bill of Exchange to UCC Contract Account numbered
123 45 6789, in the amount listed above, and is part of the Undersigneds tax estimate for
use by the Republic, and the account is charged for the fees necessary for securing and
registration (for the priority exchange for the tax exemption to discharge the public
liability is accord with HJR-192 of 5 June 1933) of the Undersigneds (preferred
stock/unalienable) rights. The Undersigned directs commanding the memory of account
numbered 123 45 6789 charging the same to the debtors order or the Secretary of the
Treasurys order. Until then I am
Very truly yours,
_______________________

c.c. IRS Memphis TN


creditor

John Henry Smith


c/o 123 Main Street
Anytown, New Jersey 07003

Please detach
Please detach

STUB

STUB

Return to: John Henry Smith


c/o 123 Main Street
Anytown, New Jersey
Date_____________
Pass Through Account # 123 45 6789
Collateral:
Proposed Individual Income Tax Assessment
Value of Bill: $__________________
STUB

Invoice # JHS1001

STUB

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