1._Attachment_A_-_2032H5-19-R-00006.pdf

Form 10160-A (8-2018) Catalog Number 71457R publish.no.irs.gov Department of the Treasury - Internal Revenue Service

ATTACHMENT A

Field Assistance Receipt for Transport of IRS Deposit

Taxpayer Assistance Center (TAC) location

Released

Date of deposit pick-up Time of deposit pick-up

IRS employee name IRS employee signature

Courier employee name Courier employee signature

Number of Bag(s) Dollar Amount in the

Bank Deposit Bag Serial Number of the

Bank Deposit Bag

Remarks

Total number of bag(s) Total dollar amount

Receipts (To be completed by the Bank)

The shipment described above was received in good condition and sealed from IRS.

Bank employee name Bank employee signature

Date Time

Form 10160-A (8-2018) Catalog Number 71457R publish.no.irs.gov Department of the Treasury - Internal Revenue Service

Instructions for Form 10160-A, Field Assistance Receipt for Transport of IRS Deposit

1. Taxpayer Assistance Center (TAC) Location: TAC name/identifier

Released

2. Date of Deposit Pick-up: The date the deposit was released to the Courier Service employee.

3. Time of Deposit Pick-up: The time the deposit was released to the Courier Service employee.

4. IRS Employee Name: The name of the designated IRS employee who released the deposit to the Courier Service employee.

5. IRS Employee Signature: The signature of the designated IRS employee who released the deposit to the Courier Service employee.

6. Courier Employee Name: The name of the designated Courier Service employee. Completed by the Courier employee.

7. Courier Employee Signature: The signature of the designated Courier Service employee. Completed by the Courier employee

8. Number of Bag(s): Enter “1” on each line for each bag listed.

9. Dollar Amount in the Bank Deposit Bag: Cash dollar amount of the deposit associated with Tamper Evident Bank Deposit Bag(s). If multiple bank deposit bags are used indicate the dollar amount in the bag that matches the serial number.

10. Serial Number of Bank Deposit Bag: Enter Serial Number of Tamper Evident Bank Deposit Bag(s). If multiple bags are used list each bags information on a separate line.

11. Remarks: Additional information associated with that Tamper Evident Bank Deposit Bag(s).

12. Total Number of Bag(s): Verify the total number of bag(s) listed. (Auto calculated, user can override)

13. Total Dollar Amount: Verify the total dollar amount of all bags listed. (Auto calculated, user can override)

Receipts (To be completed by the Bank)

14. Bank Employee Name: Bank employee’s name

15. Bank Employee Signature: Bank employee’s signature

16. Date: The date the deposit was received by the Bank Employee.

17. Time: The time the deposit was received by the Bank Employee.

Form 10160-A (8-2018) Catalog Number 71457R publish.no.irs.gov Department of the Treasury - Internal Revenue Service