State or Local Law Enforcement Application
for Reimbursement for Original Information
1. Requesting Agency Name 2. Address
3. Contact Person (Name & Title) 4. Telephone Number
( )
Individual involved in illegal drug related activities (or money laundering in connection with such activities).
5. Name 6. Address 7. SSN (If Known)
8. Summary of Information provided to the IRS (attach additional sheets, if necessary):
9. Summary of costs incurred in your investigation (including but not limited to reasonable expenses, Per diem, and overtime).
10. Have any other reimbursements been received, or applied for, for expenses incurred in the investigation of the individual named in
(2) above under any other program or arrangement including, but not limited to, Federal or state forfeiture programs, state revenue
laws, i.e., Federal and state equitable sharing arrangements.
NO
YES If yes, please attach copies of DAG-71, IRS Form 9061 or other claim for an equitable share of asset forfeitures
13. Date Violation reported11. Name of IRS employee to 12. Title
14. Certification: The requesting certifies that the above information is true and accurate
DateTitleSignature
The following is to be completed by the
Internal Revenue Service
Allowance of Reimbursement
Amount of ReimbursementSum RecoveredDistrict
$
In consideration of the original information that was furnished by the claimant named above, which concerns a violation of the
internal revenue laws and which led to the collection of taxes, penalties, and additions to tax collected in the sum shown above,
I approve payment of a reimbursement in the amount stated.
DateSignature of Service Center Director
Form 211A (3-89) Catalog Number 16572D
Department of the Treasury-Internal Revenue ServiceSee Reverse for Instruction
( )
(Month, Day, Year)
Attach additional sheets if necessary.
whom violation was reported
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signature
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