This is a new short form IRS document designed to simplify tax filing for anyone making up to $200,000 a year. The U.S. Government understands your needs and provides you with this short form in an effort to save your time (ensure increased compliance).


Fill out Section A completely by truthfully answering the questions.

Fill out Section B completely by filling in the spaces.


1. How much money do you have?________________

2. When can we come and pick it up? ______________


1. Full (current) Name: ___________ 2. Address (including name of shelter if applicable) _______________

3. Date and place of birth (attach original copy of birth certificate – will be returned to you if we can find you.) ________________

4. Present sexual preference ________________

5. Social Security and/or Identity number ________________

I swear that the information above is current and true. Should discrepances be found, I agree to be penalized to the full extent of all federal systems including the IRS and/or DHS, FBI, CIA, NEA, DEA, NSA etc.

Signature ____________________________

Witness if mark is used to sign:

I_________________ testify this is the mark of the above named person and agree to all penalties should the above information be found untruthful.

Date ___________________________