2010 Form 1040 Line 21

Supporting Schedule
Demand for Lawful Money
Per 12 USC Section 411

Name: John H. Doe

SSN: 123-45-6789
----------------------------------------------------------------------------------------------------------Form 1040 Line 21: Total Pay Reduction from Demanding Lawful Money
Net Pay
$24,580.00
Fed W/H
4,000.00
Fed MED/EE
450.00
CA W/H
1,550.00
Before Tax Ded.
2,300.00
After Tax Ded.
2,120.00
Total Gross Pay Reduction to Line 21

$35,000.00

Description: See attached copies of pay checks front and back. Also enclosed, a copy of
Title 12 United States Code Section 411 for your review.
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