CERTIFIED MAIL#

STEVE MNUCHIN
SECRETARY OF THE TREASURY
1500 PENNSYLVANIA AVENUE N.W.
WASHINGTON, D.C. 20220

Date:

RE: Debt Assessment re Public-Private Accounts

In regard to the public debt of the Debtor JOHN HENRY DOE, Tax Payer Identification Account #
(SSN WITH DASHES); Treasury Account, # (SSN WITHOUT DASHES); through the Secured Party
Aaron-Wayne: Coats, Employer Identification # (SSN WITHOUT DASHES), the Secured Party is
formally requesting a complete DEBT ASSESSMENT.

In accord with House Joint Resolution 192 of June 5th, 1933 (hereinafter HJR-192), Discharge of the
Public Debt. The DEBTOR requests said assessment so as to complete the discharge.

Concerning a Financing Statement existing between the Debtor and the Secured Party, the Debtor
wishes to notify the Secured Party of the debt incurred by DEBTOR. Please inform the DEBTOR of
any and all debt, charges, liens, or any and all accounts or assets; also a complete history of said debt
and asset assessment. The Financing Statement has been filed with the (Where your UCC 1 is filed),
and is currently being registered with the (NAME OF AGENCY UCC FILED WITH), at the
geographical location of “The State of (Your State of filing)”.

Please send this Debt Assessment to the Secured Party at the geographical location provided, signed
and certified, and charge the DEBTOR’S Treasure Account # (SSN WITHOUT DASHES)for any and
all charges and/or costs for this service.

___________________________________________________
JOHN HENRY DOE
Tax Payer Identification # 4 - - 0
Treasure Direct Account # 4 0

___________________________________________________
John Henry: Doe, sui juris
Employer Identification # 4 0

Return Acknowledgment To:

John Henry Doe
C/o 1234 Main Street
City, State [99999]

Debt Assessment Request

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