Private Issue Bill of Exchange IAW IRM 3.8.45.4.10.

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 ____________________________________________
Payable in One (1) Installment; First of Exchange at Sight Fed Wire: XXXX-XXXX-X (aka bank routing number)
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 Exempt from Levy/Good as Aval/Without Recourse
Room 3414
Washington, DC 20220 By: ___________________________________
VOID WHERE PROHIBITED BY LAW Authorized Representative/Trust Interest holder

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