Director's Stamp
Form 843 . (Date received)
(Rev. Jan. 1973) Claim

Department of the Treasury
Internal Revenue Service

The Internal Revenue Service will indicate in the block below the kind of claim filed, and fill in, where required.
C Refund of Taxes Illegally, Erroneously, or Excessively Collected.
O Refund of Amount Paid for Stamps Unused, or Used in Error or Excess.
Abatement of Tax Assessed (not applicable to income, estate or gift taxes).

&| Name of taxpayer or purchaser of stamps
Plx
6
| Number and street
El.
| City or town, State, and ZIP code
z lx
Fill in applicable items—Use attachments if necessary
a. Your social security number | Wife's number, if joint return | b. Employer identification number (if any)

x i i H !
. Internal Revenue Service office where return (if any) was filed

d, Name and address shown on return, if different from above

e. Period—if for tax reported on annual basis, prepare separate form for each taxable year | f. Kind of tax

Fromdanuary..1,.. .19.73., to ..... Recember...31,........ 19-73. | SECA and/or FICA & FUTA

g. Amount of assessment Dates of payment
$

h. Date stamps were purchased from Gov- | i. Amount to be refunded (If income tax, | j. Amount to be abated (not applicable to income,
ernment complete computation below) estate, or gift taxes)

$More than $1.00 $
k. The claimant believes that this claim should be allowed for the following reasons:
This is a Protective Claim for refund which is being filed to protect my rights
in the event the IRS determines that I and my helpers (if any) were the
employees of Brunswick Pulp and Paper Co., and/or Brunswick Pulp Land Co.
It is requested that no administrative action be taken on this claim until a
final determination is made. Please assign this claim to Howard Force, Employment
Tax Group Manager, Atlanta District.

Computation of Income Tax Refund Income Tax

1 Taxwithheld. 2 6. 2 ee ee ee
2 Estimated tax paid .
3 Tax paid with original return .
4 Any additional income tax paid . toe
5 Total tax paid (add lines1-4) . . 2 ww ee
6 Less: Your computation of correct tax
7 Amount of overpayment . 2. - 1 ee ee ee
8 Amount previously refunded .
9 Net overpayment (enter in item i above) .
Under penalties of perjury, | declare that | have examined this claim, including a accompanying schedules and statements, and to
the best of my knowledge and belief it is true, correct, and complete.

Signed ..

Dated ..........

See instructions on reverse. Form 843 (Rev. 1-73)


Instructions

1. Form 1040X or Form 1120X may
be used to amend an individual or cor-
poration income tax return. The Internal
Revenue Service prefers that they be used
rather than Form 843, since these forms
are designed to expedite processing.

2. The reasons for filing this claim
must be set forth in detail under item k.

3. Ifa joint income tax return was filed
for the year for which this claim is filed,
social security numbers of both husband
and wife should! be entered and each must
sign this claim even though only one had
income. If the taxpayer has been assigned
an employer identification number, it also
must be entered

4. The claim may be made by an agent
of the taxpayer, but the original or a true
copy of a power of attorney must accom-
pany the claim

5. If a return is filed by an individual
and a refund claim is thereafter filed by a
legal representative of the deceased, certi.
fied copies of the letters testamentary,
letters of administration, or similar evi-
dence must be attached to the claim, to
show the authority of the executor, ad
ministrator, or other fiduciary by whom
the claim is filed. If an executor, admin-
istrator, guardian, trustee, receiver, or
other fiduciary files a return and there-
after a refund claim is filed by the same
fiduciary, documentary evidence to estab-
lish the legal authority of the fiduciary
need not accompany the claim, provided
a statement is made on the claim showing
that the return was filed by the fiduciary
and that the latter is still acting.

6. Where the taxpayer is a corporation,
the officer having authority to sign for the
corporation should place his signature
and title on this claim.

7. If a claim is for excess social se-
curity (FICA) tax withheld as a result of
having more than one employer during a
calendar year, include the names and
addresses of ‘your employers, and the
amount of wages received and FICA em-
ployee tax withheld by each, as part of
your explanation in item k. Do not claim
tax withheld if you have claimed the ex
cess withholding on your individual in
come tax return.

Where to File

Certain claims relating to alcoho! and
tobacco taxes should be filed with the
Regional Director, Bureau of Alcohol, To-
bacco and Firearms. See the regulations
pertaining to the particular alcohol or to-
bacco tax. Otherwise, file your claim with
the Internal Revenue Service Center
where you filed your return.

FOR INTERNAL REVENUE SERVICE USE

ONLY

Transcript of Claimant’s Account

(Complete only as to miscellaneous excise taxes and alcohol, tobacco, and certain
other excise taxes imposed under subtitles D and E, Internal Revenue Code.)

The following is a transcript of the record of this office covering the liability that is the subject of this claim.

A—Assessed Taxes

Taxable Period

Paid, Abated, or Credited

rable Period! Document | Reference Amount i
OF fax Locator No. and Date Assessed sate or, Amount ae cr, Remarks
@ _ & © @) © a @_ wy
~~ ~~ B—Purchase of Stamps ~ —
b: ' If Special Tax Stamp, State:
i. AE Specie tex Stomp, State:
To Whom Sold or Issued kind Number Denom| ateo Amount Document Period
Locator No. Commencing
@ @ (k) 10} (m) (n) (o) (p)
Prepared by (initials) Date Office

‘Ye US, GOVERNMENT PRINTING OFFICE 1973-—O~458-212