This exhibit is a copy of Form 668-B, Levy. 1. Enter the taxpayer’s name and address. 2. Enter the taxpayer’s TIN. 3. Enter the Collection Territory. 4. Enter the type of tax, for example 1040, 1120, 941. 5. Enter the tax period. 6. Enter the unpaid balance of assessment. 7. Enter any statutory additions. 8. Enter the total amount. In the “Total amount due as of...” space, enter the date to which the accruals were computer. In the space next to the previous box, enter the total amount due of all modules on the Form 668-B. In the next paragraph there is a space for the revenue officer to enter his or her telephone number. In the space for “Date of Seizure,” enter the date the seizure is completed. In the “Signature of Revenue Officer” space, the seizing revenue officer will sign there. In the “Date” box, enter the date the revenue officer signed and submitted the form for approval.