Form 6863a - Invoice And Authorization For Payment Of Administrative Summons Expences Template - Alabama Department Of Revenue - Alabama

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A
D
R
LABAMA
EPARTMENT OF
EVENUE
FORM
6863A
Invoice and Authorization For Payment
(REV. 7/99)
of Administrative Summons Expenses
SECTION A – INVOICE
NAME, ADDRESS & TELEPHONE NUMBER OF REQUESTOR
NAME & ADDRESS OF TAXPAYER TO WHOSE LIABILITY THE SUMMONS RELATES
NAME & ADDRESS OF PAYEE
FEDERAL IDENTIFICATION NUMBER
SERVICE / FINANCIAL RECORDS PROVIDED
AMOUNTS
(See instructions on back for authorized costs and rates)
CLAIMED
1 Time spent locating and retrieving documents or information requested by the summons:
1
____________ hours @ $8.50 per hour or fraction thereof. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 Actual cost of extracting information stored by a computer
2
(show details for amounts claimed): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 Copies or duplicates of summoned documents:
3
____________ pages at 20¢ per page. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 Transportation costs
4
(show details for amounts claimed): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5 Other costs
5
(show details for amounts claimed): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
6 Total Amount Claimed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I certify that this invoice is true and correct to the best of my knowledge and belief and that payment has not been received for the
above services.
Signature of Financial Institution Official or Requestor
Title
Date Signed
SECTION B – AUTHORIZATION & CERTIFICATION
Requestor MUST NOT Use The Space Below
Date Summons Issued:
Total Amount Claimed . . . . . . . . . . . . . . . . . . . . . . . . .
Date Complied With:
Disallowance (if any) . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount to Requestor . . . . . . . . . . . . . . . . . . . . . . . . .
I certify that the articles and services listed were received and that claims for excessive and unauthorized amounts have been disal-
lowed for payment to the requestor.
Signature of Department Representative
Title
Date Signed
Payment is approved.
Signature of Department Representative
Title
Date Signed
Form 6863A

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