Clearance RecordA blank Form 178 is provided, with the following blocks to be filled in: Type of Document = NoticeDeadline Date for ClearanceDocument NumberSubjectOriginator's name, initial, office symbols and telephone numberExplanation of IssuanceProposed DistributionRouting information consisting of office symbols, name, signature, date, and commentsApprover information consisting of title, signature and dateAdministrative information consisting of date printed, date distributed, and initialsAt the bottom of the form are the following: CC Form 178 (Rev. 9-84)Department of the Treasury – Internal Revenue Service