Fillable Printable Form 433a

What is a Form 433a ?

Form 433a is also known as the Collection Information Statement for Wage Earners and Self-Employed Individuals, which is an IRS document used by individuals who owe Federal income tax that he or she cannot pay in full. Fill printable Form 433a online. Use HandyPDF to download blank or edit Form 433a online.

Fillable Printable Form 433a

What is a Form 433a ?

Form 433a

Form 433-A

(Rev. December 2012)

Department of the Treasury

Internal Revenue Service

Collection Information Statement for Wage

Earners and Self-Employed Individuals

Wage Earners Complete Sections 1, 2, 3, 4, and 5 including the signature line on page 4. Answer all questions or write N/A if the question is not applicable.

Self-Employed Individuals Complete Sections 1, 3, 4, 5, 6 and 7 and the signature line on page 4. Answer all questions or write N/A if the question is not applicable.

For Additional Information, refer to Publication 1854, "How To Prepare a Collection Information Statement."

Include attachments if additional space is needed to respond completely to any question.

Name on Internal Revenue Service (IRS) Account

Social Security Number SSN on IRS Account

Employer Identification Number EIN

Section 1: Personal Information

1a Full Name of Taxpayer and Spouse (if applicable)

1b Address (Street, City, State, ZIP code) (County of Residence)

1c Home Phone

( )

1d Cell Phone

( )

Business Phone

( )

Business Cell Phone

( )

2a Marital Status: Married

Unmarried (Single, Divorced, Widowed)

2b Name, Age, and Relationship of dependent(s)

Social Security No. (SSN) Date of Birth (mmddyyyy) Driver's License Number and State

3a Taxpayer

3b Spouse

Section 2: Employment Information for Wage Earners

If you or your spouse have self-employment income instead of, or in addition to wage income, complete Business Information in Sections 6 and 7.

Taxpayer

4a Taxpayer's Employer Name

4b Address (Street, City, State, and ZIP code)

4c Work Telephone Number

( )

Does employer allow contact at work

Yes No

How long with this employer

(years) (months)

4f Occupation

Number of withholding allowances

claimed on Form W-4

4h Pay Period:

Weekly

Monthly

Bi-weekly

Other

Spouse

Spouse's Employer Name

5b Address (Street, City, State, and ZIP code)

5c Work Telephone Number

( )

Does employer allow contact at work

Yes No

How long with this employer

(years) (months)

Occupation

Number of withholding allowances

claimed on Form W-4

5h Pay Period:

Weekly

Monthly

Bi-weekly

Other

Section 3: Other Financial Information (Attach copies of applicable documentation)

6 Are you a party to a lawsuit (If yes, answer the following) Yes No

Plaintiff Defendant

Location of Filing Represented by Docket/Case No.

Amount of Suit

Possible Completion Date (mmddyyyy)

Subject of Suit

7 Have you ever filed bankruptcy (If yes, answer the following) Yes No

Date Filed (mmddyyyy)

Date Dismissed (mmddyyyy) Date Discharged (mmddyyyy)

Petition No. Location Filed

8 In the past 10 years, have you lived outside of the U.S for 6 months or longer (If yes, answer the following) Yes No

Dates lived abroad: from (mmddyyyy)

To (mmddyyyy)

9a Are you the beneficiary of a trust, estate, or life insurance policy (If yes, answer the following) Yes No

Place where recorded: EIN:

Name of the trust, estate, or policy

Anticipated amount to be received

When will the amount be received

9b Are you a trustee, fiduciary, or contributor of a trust Yes No

Name of the trust:

EIN:

10 Do you have a safe deposit box (business or personal) (If yes, answer the following) Yes No

Location (Name, address and box number(s)) Contents

Value

www.irs.gov Cat. No. 20312N

Form 433-A (Rev.12-2012)

In the past 10 years, have you transferred any assets for less than their full value (If yes, answer the following)

Yes No

List Asset(s) Value at Time of Transfer

Date Transferred (mmddyyyy)

To Whom or Where was it Transferred

Form 433-A (Rev. 12-2012) Page 2

Section 4: Personal Asset Information for All Individuals

12 CASH ON HAND Include cash that is not in a bank Total Cash on Hand

PERSONAL BANK ACCOUNTS Include all checking, online and mobile (e.g., PayPal) accounts, money market accounts, savings accounts, and

stored value cards (e.g., payroll cards, government benefit cards, etc.).

Total Available Cash (Subtract amounts on line 16f from line 16e and include amounts from any attachments)

Form 433-A (Rev. 12-2012)

Type of Account

Full Name & Address (Street, City, State, ZIP code) of Bank,

Savings & Loan, Credit Union, or Financial Institution

Account Number

Account Balance

As of

mmddyyyy

13a $

13b $

13c $

13d Total Cash (Add lines 13a through 13c, and amounts from any attachments)

INVESTMENTS Include stocks, bonds, mutual funds, stock options, certificates of deposit, and retirement assets such as IRAs, Keogh, and 401(k)

plans. Include all corporations, partnerships, limited liability companies, or other business entities in which you are an officer, director, owner,

member, or otherwise have a financial interest.

Type of Investment

or Financial Interest

Full Name & Address

(Street, City, State, ZIP code) of Company

Current Value

Loan Balance (if applicable)

As of

mmddyyyy

Equity

Value minus Loan

14a

Phone $ $ $

14b

Phone $ $ $

14c

Phone

$ $ $

14d Total Equity (Add lines 14a through 14c and amounts from any attachments)

AVAILABLE CREDIT Include all lines of credit and bank issued credit cards.

Full Name & Address (Street, City, State, ZIP code) of Credit Institution

Credit Limit

Amount Owed

As of

mmddyyyy

Available Credit

As of

mmddyyyy

15a

Acct. No

$ $ $

15b

Acct. No $ $ $

15c Total Available Credit (Add lines 15a, 15b and amounts from any attachments) $

16a

LIFE INSURANCE Do you own or have any interest in any life insurance policies with cash value (Term Life insurance does not have a cash value)

Yes No

If yes, complete blocks 16b through 16f for each policy.

16b

Name and Address of Insurance

Company(ies):

16c Policy Number(s)

16d Owner of Policy

16e Current Cash Value $

16f Outstanding Loan Balance $

16g $

Form 433-A (Rev. 12-2012) Page 3

REAL PROPERTY Include all real property owned or being purchased

Purchase Date

(mmddyyyy)

Current Fair

Market Value

(FMV)

Current Loan

Balance

Amount of

Monthly Payment

Date of Final

Payment

(mmddyyyy)

Equity

FMV Minus Loan

17a Property Description

$ $ $ $

Location (Street, City, State, ZIP code) and County

Lender/Contract Holder Name, Address (Street, City, State, ZIP code), and Phone

Phone

17b Property Description

$ $ $ $

Location (Street, City, State, ZIP code) and County

Lender/Contract Holder Name, Address (Street, City, State, ZIP code), and Phone

Phone

17c Total Equity (Add lines 17a, 17b and amounts from any attachments) $

PERSONAL VEHICLES LEASED AND PURCHASED Include boats, RVs, motorcycles, all-terrain and off-road vehicles, trailers, etc.

Description (Year, Mileage, Make/Model,

Tag Number, Vehicle Identification Number)

18a Year Make/Model

Mileage License/Tag Number

Vehicle Identification Number

Purchase/

Lease Date

(mmddyyyy)

Current Fair

Market Value

(FMV)

Current Loan

Balance

Amount of

Monthly Payment

Date of Final

Payment

(mmddyyyy)

Equity

FMV Minus Loan

Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone

Phone

18b Year Make/Model

Mileage License/Tag Number

Vehicle Identification Number

$ $ $ $

Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone

Phone

18c Total Equity (Add lines 18a, 18b and amounts from any attachments) $

Purchase/

Lease Date

(mmddyyyy)

Current Fair

Market Value

(FMV)

Current Loan

Balance

Amount of

Monthly Payment

Date of Final

Payment

(mmddyyyy)

Equity

FMV Minus Loan

19a Property Description

$ $ $ $

Location (Street, City, State, ZIP code) and County Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone

Phone

19b Property Description

$ $ $ $

Location (Street, City, State, ZIP code) and County Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone

Phone

19c Total Equity (Add lines 19a, 19b and amounts from any attachments)

Form 433-A (Rev. 12-2012)

PERSONAL ASSETS Include all furniture, personal effects, artwork, jewelry, collections (coins, guns, etc.), antiques or other assets. Include

intangible assets such as licenses, domain names, patents, copyrights, mining claims, etc.

Form 433-A (Rev. 12-2012) Page 4

If you are self-employed, sections 6 and 7 must be completed before continuing.

Section 5: Monthly Income and Expenses

Monthly Income/Expense Statement (For additional information, refer to Publication 1854.)

Total Income

Source

Gross Monthly

20 Wages (Taxpayer)

21 Wages (Spouse)

22 Interest - Dividends $

23 Net Business Income

24 Net Rental Income

25 Distributions (K-1, IRA, etc.)

26 Pension (Taxpayer) $

27 Pension (Spouse) $

28 Social Security (Taxpayer) $

29 Social Security (Spouse) $

30 Child Support $

31 Alimony $

Other Income (Specify below)

32 $

33 $

34 Total Income (add lines 20-33) $

Total Living Expenses

Expense Items

Actual Monthly

35 Food, Clothing and Misc.

36 Housing and Utilities

37 Vehicle Ownership Costs

38 Vehicle Operating Costs

39 Public Transportation

40 Health Insurance $

41 Out of Pocket Health Care Costs

42 Court Ordered Payments $

43 Child/Dependent Care $

44 Life Insurance $

45 Current year taxes (Income/FICA)

46 Secured Debts (Attach list) $

47 Delinquent State or Local Taxes $

48 Other Expenses (Attach list) $

49 Total Living Expenses (add lines 35-48)

50 Net difference (Line 34 minus 49) $

IRS USE ONLY

Allowable Expenses

Wages, salaries, pensions, and social security: Enter gross monthly wages and/or salaries. Do not deduct tax withholding or allotments taken

out of pay, such as insurance payments, credit union deductions, car payments, etc. To calculate the gross monthly wages and/or salaries:

If paid weekly - multiply weekly gross wages by 4.3. Example: $425.89 x 4.3 = $1,831.33

If paid biweekly (every 2 weeks) - multiply biweekly gross wages by 2.17. Example: $972.45 x 2.17 = $2,110.22

If paid semimonthly (twice each month) - multiply semimonthly gross wages by 2. Example: $856.23 x 2 = $1,712.46

2 Net Income from Business: Enter monthly net business income. This is the amount earned after ordinary and necessary monthly business

expenses are paid. This figure is the amount from page 6, line 89. If the net business income is a loss, enter “0”. Do not enter a negative

number. If this amount is more or less than previous years, attach an explanation.

3 Net Rental Income: Enter monthly net rental income. This is the amount earned after ordinary and necessary monthly rental expenses are

paid. Do not include deductions for depreciation or depletion. If the net rental income is a loss, enter “0.” Do not enter a negative number.

4 Distributions: Enter the total distributions from partnerships and subchapter S corporations reported on Schedule K-1, and from limited

liability companies reported on Form 1040, Schedule C, D or E. Enter total distributions from IRAs if not included under pension income.

Other Income: Include agricultural subsidies, unemployment compensation, gambling income, oil credits, rent subsidies, etc.

Expenses not generally allowed: We generally do not allow tuition for private schools, public or private college expenses, charitable

contributions, voluntary retirement contributions or payments on unsecured debts. However, we may allow the expenses if proven that they are

necessary for the health and welfare of the individual or family or the production of income. See Publication 1854 for exceptions.

Food, Clothing and Miscellaneous: Total of food, clothing, housekeeping supplies, and personal care products for one month. The

miscellaneous allowance is for expenses incurred that are not included in any other allowable living expense items. Examples are credit card

payments, bank fees and charges, reading material, and school supplies.

Housing and Utilities: For principal residence: Total of rent or mortgage payment. Add the average monthly expenses for the following:

property taxes, homeowner’s or renter’s insurance, maintenance, dues, fees, and utilities. Utilities include gas, electricity, water, fuel, oil,

other fuels, trash collection, telephone, cell phone, cable television and internet services.

Vehicle Ownership Costs: Total of monthly lease or purchase/loan payments.

Vehicle Operating Costs: Total of maintenance, repairs, insurance, fuel, registrations, licenses, inspections, parking, and tolls for one month.

Public Transportation: Total of monthly fares for mass transit (e.g., bus, train, ferry, taxi, etc.)

Out of Pocket Health Care Costs: Monthly total of medical services, prescription drugs and medical supplies (e.g., eyeglasses, hearing aids, etc.)

Current Year Taxes: Include state and Federal taxes withheld from salary or wages, or paid as estimated taxes.

Certification: Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities, and other

information is true, correct, and complete.

Taxpayer's Signature Spouse's signature Date

After we review the completed Form 433-A, you may be asked to provide verification for the assets, encumbrances, income and expenses

reported. Documentation may include previously filed income tax returns, pay statements, self-employment records, bank and investment

statements, loan statements, bills or statements for recurring expenses, etc.

IRS USE ONLY (Notes)

Form 433-A (Rev. 12-2012)

Form 433-A (Rev. 12-2012) Page 5

Sections 6 and 7 must be completed only if you are SELF-EMPLOYED.

Section 6: Business Information

Is the business a sole proprietorship (filing Schedule C)

Yes, Continue with Sections 6 and 7. No, Complete Form 433-B.

All other business entities, including limited liability companies, partnerships or corporations, must complete Form 433-B.

Business Name & Address (if different than 1b)52

Employer Identification Number

Type of Business Is the business a

Federal Contractor

Yes No

56 Business Website (web address)

Total Number of Employees

Average Gross Monthly Payroll

59 Frequency of Tax Deposits 60 Does the business engage in e-Commerce

(Internet sales) If yes, complete lines 61a and 61b

Yes No

PAYMENT PROCESSOR (e.g., PayPal, Authorize.net, Google Checkout, etc.) Name & Address (Street, City, State, ZIP code)

Payment Processor Account Number

61a

61b

CREDIT CARDS ACCEPTED BY THE BUSINESS

Credit Card Merchant Account Number Issuing Bank Name & Address (Street, City, State, ZIP code)

62a

62b

62c

63 BUSINESS CASH ON HAND Include cash that is not in a bank. Total Cash on Hand $

BUSINESS BANK ACCOUNTS Include checking accounts, online and mobile (e.g., PayPal) accounts, money market accounts, savings accounts,

and stored value cards (e.g., payroll cards, government benefit cards, etc.). Report Personal Accounts in Section 4.

Type of Account

Full name & Address (Street, City, State, ZIP code)

of Bank,Savings & Loan, Credit Union or Financial Institution.

Account Number

Account Balance

As of

mmddyyyy

64a $

64b $

64c Total Cash in Banks (Add lines 64a, 64b and amounts from any attachments) $

ACCOUNTS/NOTES RECEIVABLE Include e-payment accounts receivable and factoring companies, and any bartering or online auction accounts.

(List all contracts separately, including contracts awarded, but not started.) Include Federal, state and local government grants and contracts.

Accounts/Notes Receivable & Address (Street, City, State, ZIP code)

Status (e.g., age,

factored, other)

Date Due

(mmddyyyy)

Invoice Number or Government

Grant or Contract Number

Amount Due

65a $

65b $

65c $

65d $

65e $

65f Total Outstanding Balance (Add lines 65a through 65e and amounts from any attachments) $

Form 433-A (Rev. 12-2012)

Form 433-A (Rev. 12-2012) Page 6

Section 7: Sole Proprietorship Information (lines 67 through 87 should reconcile with business Profit and Loss Statement)

Form 433-A (Rev. 12-2012)

BUSINESS ASSETS Include all tools, books, machinery, equipment, inventory or other assets used in trade or business. Include a list and show the

value of all intangible assets such as licenses, patents, domain names, copyrights, trademarks, mining claims, etc.

Purchase/

Lease Date

(mmddyyyy)

Current Fair

Market Value

(FMV)

Current Loan

Balance

Amount of

Monthly Payment

Date of Final

Payment

(mmddyyyy)

Equity

FMV Minus Loan

66a Property Description

$ $ $ $

Location (Street, City, State, ZIP code) and Country

Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code), and Phone

Phone

66b Property Description

$ $ $ $

Location (Street, City, State, ZIP code) and Country

Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code), and Phone

Phone

66c Total Equity (Add lines 66a, 66b and amounts from any attachments) $

Section 7 should be completed only if you are SELF-EMPLOYED

Accounting Method Used: Cash Accrual

Income and Expenses during the period (mmddyyyy) to (mmddyyyy)

Total Monthly Business Income

Source Gross Monthly

67 Gross Receipts $

68 Gross Rental Income $

69 Interest $

70 Dividends $

71 Cash Receipts not included in lines 67-70 $

Other Income (Specify below)

76 Total Income (Add lines 67 through 75) $

Total Monthly Business Expenses (Use attachments as needed)

Expense Items Actual Monthly

77 Materials Purchased

78 Inventory Purchased

79 Gross Wages & Salaries $

80 Rent $

81 Supplies

82 Utilities/Telephone

83 Vehicle Gasoline/Oil $

84 Repairs & Maintenance $

85 Insurance $

86 Current Taxes

Other Expenses, including installment payments

(Specify) $

88 Total Expenses (Add lines 77 through 87) $

89 Net Business Income (Line 76 minus 88)

Enter the monthly net income amount from line 89 on line 23, section 5. If line 89 is a loss, enter "0" on line 23, section 5.

Self-employed taxpayers must return to page 4 to sign the certification.

1 Materials Purchased: Materials are items directly related to the

production of a product or service.

2 Inventory Purchased: Goods bought for resale.

3 Supplies: Supplies are items used in the business that are

consumed or used up within one year. This could be the cost of books,

office supplies, professional equipment, etc.

4 Utilities/Telephone: Utilities include gas, electricity, water, oil, other

fuels, trash collection, telephone, cell phone and business internet.

5 Current Taxes: Real estate, excise, franchise, occupational,

personal property, sales and employer’s portion of employment taxes.

6 Net Business Income: Net profit from Form 1040, Schedule C may

be used if duplicated deductions are eliminated (e.g., expenses for

business use of home already included in housing and utility expenses

on page 4). Deductions for depreciation and depletion on Schedule C

are not cash expenses and must be added back to the net income

figure. In addition, interest cannot be deducted if it is already included in

any other installment payments allowed.

IRS USE ONLY (Notes)

Use the prior 3, 6, 9 or 12 month period to determine your typical business income and expenses.

Provide a breakdown below of your average monthly income and expenses, based on the period of time used above.