Claiming exemption

1234, Main Street
Boston, MA 02123

05 April, 2005

<Recipient Address Goes Here>

Hello,

I assert that I am exempt from paying federal income tax for <year>, because <reason>.

If there is some error in this statement of exemption, please notify me of it immediately. Thank you.

Regards,

Robert Anderson

encl: <List of enclosed items goes here>

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