Private Issue Bill of Exchange IAW IRM

1 (01-01-2010) Issued under Safe Harbor IAW Title 26 Subtitle A Chapter 1 Subchapter J Part 1 Subpart E Section 674(b)(5)(b) Place of Drawing: __Your town/state______________ Date: _________________ No. Your BOE Series Number

Pay to the Order of: _______________ENTITY NAME and ADDRESS________________________________________________ Account No. __________ Account Holder Name ____________________________________________ Fed Wire: XXXX-XXXX-X (aka bank routing number)

Payable in One (1) Installment; First of Exchange at Sight

Amount: ____________________________________________________ USD $____________________________ and no 100s Value Received and Charge to Account of: Your Upper Lower Name________________________________________________ Prepaid U.S. Treasury Account No. Your Social Security Number without dashes
To: Department of the Treasury Office of Executive Secretary

Drawer and Location

1500 Pennsylvania Avenue, NW Room 3414 Washington, DC 20220 VOID WHERE PROHIBITED BY LAW

Exempt from Levy/Good as Aval/Without Recourse By: ___________________________________
Authorized Representative/Trust Interest holder

DELETE THIS BOX BEFORE PRINTING The above rectangle is called a text box. Click the border and it will be outlined. On the bottom line, notice a small circle. Position your cursor so the up/down arrow appears. Now drag the text box down to expand, if absolutely necessary. Definitions of a Bill of Exchange, would have it sized like a check.

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