Date: Today’s Date, 2021 Invoice # EX98765

**(supply your own invoice number – can be anything)**

Registered / Certified Mail # xxxx xxxx xxxx xxxx xxxx

BILL OF EXCHANGE
NON-NEGOTIABLE
PRIVATE ISSUE

Pass-Through Account # SSN-xx-xxxx

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

U.C.C. § 3-419, HJR-192 of 5 June 1933, Public Law § 73-10, and Registered Adjustment of Account:

Collateral: Case # or Creditor Bill # xxxxxxxxxx

Value of Bill: $ _________________________________.

The Undersigned accepts for value, honor, and consideration all indorsements front and back and includes
those in accord with U.C.C. § 3-419 as evidence with the herein Bill of Exchange to U.C.C. Contract
Account # SSN-xx-xxxx in the amount listed below and is part of the Undersigned’s tax estimate for use by
the Republic, and the account is charged for the fees necessary for securing and registering the priority
exchange for the tax exemption to discharge the public liability in accord with HJR-192 of 5 June 1933 and
Public Law § 73-10. The Undersigned directs commanding the memory of account # SSN-xx-xxxx and
charging the same to the debtor’s order or to the Secretary of the Treasury’s order.
Without Recourse,

By:___________________________________

First Middle Last, as Surety

for FIRST MIDDLE LAST, Payor
c/o 1234 Your Address Street
City / Town, State [12345]

………………………………………………………………………………………………………………………………………
Please detach Please detach

Return to: First Middle Last

Date: Date 1, 2020 c/o 1234 Your Address Street
City / Town, State, nearby [12345]

Invoice # InvoiceNumFromTop
Pass-Through Account #: SSN-xx-xxxx
Collateral: Case # or Bill # xxxxxxxxxx
Pay to: UNITED STATES TREASURY
For Credit to: COURT / BUSINESS NAME GOES HERE Indorsement of Payor:

Value of Bill: $ __________________ ______________________

Authorized Representative
without recourse
Written Amount: _________________________________________ Dollars
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