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[[preprinted]]
TREASURY DEPARTMENT
INTERNAL REVENUE BUREAU
Form No. 7801 - Jan., 1922
January 18, 1922

Washington, D. C.

NOTICE OF ADJUSTMENT OF CLAIM FOR REFUND

^[[checkmark]]
^[[ST-LS checkmark]]

Claim No. ^[[307191]]
District ^[[2 N. Y.]]
Schedule No. [[stamp]] 3T-R639 [[/stamp]]

^[[Jacques Seligmann & Co., Inc.,
705 Fifth Avenue,
New York, N. Y.]]

Your claim for refund of ^[[miscellaneous excise]]
tax erroneously or illegally collected, has been adjusted as shown below.

Claimed $^[[45.25]] 
Allowed $^[[45.25]]
Rejected $
DATE OF PAYMENT

^[[Send to Mr. Coe]]

A check by the Disbursing Clerk of the Department for the amount refunded is forwarded herewith.

Respectfully, 

[[signature]] R. M. Estes [[/signature]]
Deputy Commissioner

GOVERNMENT PRINTING OFFICE   2-11716 [[/preprinted]]

EMT