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IN THE UNITED STATES DISTRICT COURT FOR THE
_________ DISTRICT OF ___________
____________ Division
UNITED STATES OF AMERICA )
)
v. ) CRIMINAL NO.
)
)
ORDER FOR DISCLOSURE OF
RETURNS AND RETURN INFORMATION
On this _____ day of ______, 19____, comes for the attention of the
Court the application of the United States Attorney for the _____________
District of __________ for an ex parte order, pursuant to 26
U.S.C.
6103(i)(5), directing the Internal Revenue Service to disclose returns and
return
information of:
NAME:
ADDRESS:
SOCIAL SECURITY NUMBER:
for taxable period(s) of ____________________________. After examining the
application the Court finds:
(1) A federal arrest warrant relating to the commission of the
Federal
felony offense (s) of (LIST OFFENSE(s)
____________________________________________________________________________
has been issued for the individual named above who is a fugitive from
justice.
(2) There is reasonable cause to believe that such return or
return
information may be relevant in determining the location of such individual.
IT IS THEREFORE ORDERED that the Internal Revenue Service:
(1) disclose such returns and return information of:
NAME:
ADDRESS:
SOCIAL SECURITY NUMBER:
for the taxable period(s) ___________________________ as have been filed and
are
on file with the Internal Revenue Service;
(2) disclose such returns and return information described above as
come into the possession of the Internal Revenue Service subsequent to the
date
of this order, but for not longer than 90 days thereafter;
(3) disclose such returns and return information only to applicant
and
NAME:
TITLE:
AGENCY:
and to no other person;
(4) disclose no returns or return information not described above.
It is further ORDERED that applicant and
NAME:
TITLE:
AGENCY:
and any officer or employee of any Federal agency who may be subsequently
assigned in this matter shall use the returns and return information
disclosed
solely in locating the above-named fugitive, and that no disclosure be made
to
any other person except in accordance with the provision of 26 U.S.C.
§
6103.
___________________________________
UNITED STATES DISTRICT JUDGE
DATED: _____________________
VERIFICATION
I, ________________, being first duly sworn, depose and say that I
am
an Assistant United States Attorney for the ___________ District of
___________
and that the foregoing Application is made on the basis of information
officially
furnished and upon the basis that such information is true as I verily
believe.
________________________________
Assistant United States Attorney
Subscribed and sworn to before
me this _____ day of _________,
19_____.
My Commission Expires:
_______________________________
Notary Public
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