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Get IRS 433-D 2015

Review Cycle Check box if pre-assessed modules included Originator s ID number NOTE: A NOTICE OF FEDERAL TAX LIEN WILL NOT BE FILED ON ANY PORTION OF YOUR LIABILITY WHICH REPRESENTS AN INDIVIDUAL SHARED RESPONSIBILITY PAYMENT UNDER THE AFFORDABLE CARE ACT. Originator Code Name Title Date Agreement examined or approved by (Signature, title, function) Catalog Number 16644M MAY BE FILED IF THIS AGREEMENT DEFAULTS www.irs.gov Part 1 IRS Copy Form 433-D (Rev. 1-2015) Form Depar.

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