Form 14135 - Application For Certificate Of Discharge Of Property From Federal Tax Lien Page 3
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10. Copy of Federal Tax Lien(s)
(Complete if applicant and taxpayer differ)
Attached
No
OR list the lien number(s) found near the top right corner on the lien document(s)
(if known)
11. Copy of the sales contract/purchase agreement
Attached
No
(if available)
OR
Describe how and when the taxpayer will be divested of his/her interest in the property:
12. Copy of a current title report
Attached
No
OR
List encumbrances senior to the Federal Tax Lien. Include name and address of holder; description of encumbrance,
e.g., mortgage, state lien, etc.; date of agreement; original loan amount and interest rate; amount due at time of
application; and family relationship, if applicable
:
(Attach additional sheets as needed)
13. Copy of proposed closing statement
Attached
No
(aka HUD-1)
OR
Itemize all proposed costs, commissions, and expenses of any transfer or sale associated with property
(Attach
additional sheets as needed):
14. Additional information that may have a bearing on this request, such as pending
Attached
No
litigation, explanations of unusual situations, etc., is attached for consideration
15. Escrow Agreement
(For applications under IRC 6325(b)(3))
Attached
No
Escrow agreement must specify type of account, name and depositary for account,
conditions under which payment will be made, cost of escrow, name and address of any
party identified as part of escrow agreement, and signatures of all parties involved including
Advisory Group Manager. Terms for agreement must be reached before discharge approved.
16. WAIVER
(For applications made by third parties under IRC 6325(b)(2))
If you are applying as an owner of the property and you are not the taxpayer, to have this application considered under section
6325(b)(2), you must waive the rights that would be available if the application were made under section 6325(b)(4). If you choose
not to waive these rights, the application will be treated as one made under 6325(b)(4) and any payment will be treated like a
deposit under that section. Please check the appropriate box.
I understand that an application and payment made under section 6325(b)(2) does not provide the judicial remedy
available under section 7426(a)(4). In making such an application / payment, I waive the option to have the payment
treated as a deposit under section 6325(b)(4) and the right to request a return of funds and to bring an action under
section 7426(a)(4).
Waive
No
17. Declaration
Under penalties of perjury, I declare that I have examined this application, including any accompanying schedules, exhibits,
affidavits, and statements and to the best of my knowledge and belief it is true, correct and complete.
Signature/Title
Date
Signature/Title
Date
Catalog Number 54727S
14135
Form
(Rev. 06-2010)
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