State or Local Law Enforcement Application
for Reimbursement for Original Information
1. Requesting Agency Name
3. Contact Person
4. Telephone Number
(Name & Title)
Individual involved in illegal drug related activities
(or money laundering in connection with such activities).
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)
Attach additional sheets if necessary.
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.
If yes, please attach copies of DAG-71, IRS Form 9061 or other claim for an equitable share of asset forfeitures
11. Name of IRS employee to
13. Date Violation reported
whom violation was reported
14. Certification: The requesting certifies that the above information is true and accurate
The following is to be completed by the
Internal Revenue Service
Allowance of Reimbursement
Amount of Reimbursement
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.
Signature of Service Center Director
Catalog Number 16572D
See Reverse for Instruction
Department of the Treasury-Internal Revenue Service