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.)
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)
34 Total Income (add lines 20-33) $
Total Living Expenses
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
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)