ACCEPTED FOR VALUE Exempt from Levy
By: ___________________________ Date: ___________
Authorized Representative
Exemption ID# 123456789
DEPOSIT TO THE U.S. TREASURY AND CHARGE THE SAME TO JOHN H DOE 123-45-6789
ACCEPTED FOR VALUE Exempt from Levy
By: ___________________________ Date: ___________
Authorized Representative
Exemption ID# 123456789
DEPOSIT TO THE U.S. TREASURY AND CHARGE THE SAME TO JOHN H DOE 123-45-6789