REGISTRATION# (CERTIFIED MAIL# 1111 1111 1111 1111 1111 RRR)
John Henry Doe
c/o [Mailing address] [Address]
Steven Terner Mnuchin, Trustee
US Department of the Treasury 1500
Pennsylvania Avenue, NW Washington, DC 20220
Re: Account #
Date
NOTICE OF PREAUTHORIZED USE OF CREDIT
Certified # [# used to mail acceptance to creditor]
Registration # [# use to mail this notice to Steven Terner Mnuchin]
Mr. Mnuchin:
I hereby authorize ABC Corporation to use my exemption, through FedWire through the TTL
account of Claimant’s Bank, to settle the above-referenced account, by adjustment and offset
through the undersigned’s private Setoff Account, as follows:
Credit to the Order Of: ABC Corporation
Amount: Forty Nine Thousand Dollars and 00/100 $ 49,000.00
[value written in words] and no/100 Account # [to be supplied by current
beneficiary. Example: Payoff Statement]
For Further Credit To: [Account number from bill or presentment]
Debtor: JOHN H DOE 123-45-6789
Setoff Account# 123456789 - [closed account # SSN without Dashes]
***Registered with the Department of the Treasury «Original Registered Mail # from
Bond held by Secretary of the Treasury»***
Please use my private Set-Off Account for the adjustment of fees associated with this
authorization.
By___________________________
John Henry Doe Bond# 123456789
Attachments:
copy of [whatever was accepted and returned with a $ amount on it. Example :Billing Statement,
Payoff Notice] cc: file
Void Where Prohibited by Law
NOTICE OF PREAUTHORIZED USE OF CREDIT