Accepted for value

Exempt from Levy

x___________________________ Date 01-12-2010

Exemption ID

Number 540556666

Deposit to th

e U.S. Treasury and Charge th

e same to

THOMAS JAY SMITH

540-55-6666

DELETE and Handwrite this on the IRS bill or whatever bill you are paying:

THIS IS A MONEY ORDER

Pay to the order of U.S Treasury DATEEight thousand four hundred dollars $8400.00

(endorse back as you would a check)

By Thomas Jay Smith 540556666Authorized representative

ACCEPTANCE OF WAREHOUSE RECEIPT IS PAID IN FULLDELETE: On reverse endorse like a check: Sign Yourame – authorized representative