Charge Back Secretary Treasury Template

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Your-Name: Here

without prejudice
c/o 123 Your Address Ln.
City, State Republic [12345]

Date: Date

STEVEN MNUCHIN – Secretary of the Treasury, or his Successor


1500 PENNSYLVANIA AVENUE NW
WASHINGTON, DC 20220
“NON-NEGOTIABLE”
“Non-transferable”
“CHARGE BACK”
Dear Mr. Lew:

I accept for value all related endorsements in accordance with U.C.C. 3-419, HJR 192 of 5 June 1933,
Public Law 48 (48 stat. 112), and Public Law 73-10. Charge my UCC Contract Trust Account # SEE
UCC-1 CertMailNum-EIN for the registration fees and command the memory of account to charge the
same to the Debtor’s order, or your Order.

The total amount of this BONDED, NON-NEGOTIABLE ACCEPTANCE FOR VALUE in the enclosed
filing is $_____.

Receipt of the Certified Mail Return Receipt is hereby accepted as acknowledgement that my Personal
Certified UCC Contract Trust Account # SEE UCC-1 CertMailNum-EIN is activated through the
Secretary of the Treasury.

Thank you for your help in this matter. If you have any questions or need my assistance, please feel free
to contact me.

Posted: Certified Trust # SEE UCC-1 CertMailNum- Very truly,


EIN
ATTACHED INVOICE NUMBERS:
______________________________________
_______birth certificate number_____________ Your-Name: Here, Secured Party
_______________________________________ Trustee, but not individually
Employer Identification # 123456789
c/o 1234 Your Address Lane
City, State Republic, near [12345]
Bond # SEE BACK OF Social Security card
Pre-paid – Preferred Stock
Priority - Exempt from Levy

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