CERTIFICATE OF NON-RESPONSE

STATE OF CALIFORNIA
COUNTY OF ORANGE
PRESENTMENT

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Be it known, that, the person signing below, a duly empowered Notary Public, at the request

1332 Main Street, Some City, California 90210

John Henry Doe
of_____________________________ In care of __________________________________________________:
Claimant

Address

CONSTRUCTIVE NOTICE OF CONDITIONAL ACCEPTANCE; and

June 24, 2009
June 25, 2009
AFFIDAVIT
did duly present on ________________ the attachedCOMMERCIAL
________________________________________________
dated _______________
Internal Revenue Service, Attn: Maureen Green M/S 4450, 1973 North Rulon White Blvd., Ogden, UT 84004-7843
to _____________________________________________________________________________________________________________
Respondent(s)

John Henry Doe

Point-by-point response via affidavit
signed by ___________________________ requesting _________________________________________________________________,
the time limit having elapsed for a timely response thereto.
DEFAULT
Whereupon, the Notary Public signing below, for the reason dishonor by non-response, does publicly and solemnly certify
the dishonor as against all parties it may concern by reason of non-response thereof and stipulations therein.
NAME

ADDRESS

INTERNAL REVENUE SERVICE

1973 North Rulon White Blvd.

Attn: Maureen Green M/S 4450

Ogden, UT 84004-7843

_________________________________
_________________________________
_________________________________
TESTIMONY

________________________________________________
________________________________________________
________________________________________________

In testimony of the above, I have signed my name and attached my official seal

___________________________________________
Notary Public
August 24, 2010
My commission expires: __________________
August 27, 2009
Date __________________