Form

433-A

(Rev. January 2008)

Department of the Treasury Internal Revenue Service

Collection Information Statement for Wage Earners and Self-Employed Individuals

Wage Earners Complete Sections 1, 2, 3, and 4, including signature line on page 4. Answer all questions or write N/A. Self-Employed Individuals Complete Sections 1, 2, 3, 4, 5 and 6 and signature line on page 4. Answer all questions or write N/A. 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

( (

) )

( (

) )

1e Business Phone

1f Business Cell Phone

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

2a Marital Status: 3a Taxpayer 3b Spouse

Unmarried (Single, Divorced, Widowed) Married Social Security No. (SSN) Date of Birth (mmddyyyy)

Drivers License Number and State

Section 2: Employment Information If the taxpayer or spouse is self-employed or has self-employment income, also complete Business Information in Sections 5 and 6. Taxpayer Spouse
4a Taxpayers Employer Name 4b Address (Street, City, State, ZIP code) 5a Spouses Employer Name 5b Address (Street, City, State, ZIP code)

4c Work Telephone Number

4d Does employer allow contact at work Yes Occupation No

5c Work Telephone Number

5d Does employer allow contact at work Yes Occupation No

4e How long with this employer 4f (years) (months) 4g Number of exemptions claimed on Form W-4

5e How long with this employer 5f (years) (months) 5g Number of exemptions claimed on Form W-4

4h Pay Period: Weekly Monthly

Bi-weekly Other

5h Pay Period: Weekly Monthly

Bi-weekly Other

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

6 Is the individual or sole proprietorship party to a lawsuit (If yes, answer the following) Location of Filing Plaintiff Amount of Suit $ 7 Has the individual or sole proprietorship ever filed bankruptcy (If yes, answer the following) Date Filed (mmddyyyy) 8 Date Dismissed or Discharged (mmddyyyy) Petition No. Defendant Possible Completion Date (mmddyyyy) Subject of Suit Represented by

Yes

No

Docket/Case No.

Yes
Location

No

Any increase/decrease in income anticipated (business or personal) (If yes, answer the following) Explain. (Use attachment if needed) $ How much will it increase/decrease

Yes

No

When will it increase/decrease

Is the individual or sole proprietorship a beneficiary of a trust, estate, or life insurance policy
(If yes, answer the following) Place where recorded: Name of the trust, estate, or policy $ Anticipated amount to be received EIN:

Yes

No

When will the amount be received

10

In the past 10 years, has the individual resided outside of the United States for periods of 6 months or longer (If yes, answer the following) Dates lived abroad: from (mmddyyyy) To (mmddyyyy)
Cat. No. 20312N

Yes

No

www.irs.gov

Form

433-A

(Rev. 1-2008)

Form 433-A (Rev. 1-2008)

Page

Section 4: Personal Asset Information for All Individuals

11 Cash on Hand. Include cash that is not in a bank. Total Cash on Hand $

Personal Bank Accounts. Include all checking, online bank accounts, money market accounts, savings accounts, stored value cards (e.g., payroll cards, government benefit cards, etc.) List safe deposit boxes including location and contents.
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

12a $ 12b $ 12c Total Cash (Add lines 12a, 12b, 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 the individual is an officer, director, owner, member, or otherwise has 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

13a

Phone 13b

Phone 13c

Phone

$ $
Amount Owed As of ____________
mmddyyyy

13d Total Equity (Add lines 13a through 13c and amounts from any attachments) Available Credit. List bank issued credit cards with available credit.
Full Name & Address (Street, City, State, ZIP code) of Credit Institution Credit Limit

Available Credit As of ____________

mmddyyyy

14a

Acct No.: 14b

Acct No.: 14c

$ $

Total Available Credit (Add lines 14a, 14b and amounts from any attachments)

15a Life Insurance. Does the individual have life insurance with a cash value (Term Life insurance does not have a cash value.) If Yes complete blocks 15b through 15f for each policy: Yes No 15b Name and Address of Insurance Company(ies):

15c 15d 15e 15f

Policy Number(s) Owner of Policy Current Cash Value Outstanding Loan Balance

$ $

$ $

$ $ $
Form

15g Total Available Cash. (Subtract amounts on line 15f from line 15e and include amounts from any attachments)

433-A

(Rev. 1-2008)

Form 433-A (Rev. 1-2008)

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16

In the past 10 years, have any assets been transferred by the individual for less than full value (If yes, answer the following. If no, skip to 17a) List Asset $ Real Property Owned, Rented, and Leased. Include all real property and land contracts.
Purchase/Lease Date (mmddyyyy) Current Fair Market Value (FMV) Current Loan Balance Amount of Monthly Payment Date of Final Payment (mmddyyyy)

Yes

No

Value at Time of Transfer

Date Transferred (mmddyyyy)

To Whom or Where was it Transferred

Equity FMV Minus Loan

17a Property Description $ Location (Street, City, State, ZIP code) and County $ $ $ Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and Phone

17b Property Description $ Location (Street, City, State, ZIP code) and County $ $ $ Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and Phone

17c Total Equity (Add lines 17a, 17b and amounts from any attachments) Personal Vehicles Leased and Purchased. Include boats, RVs, motorcycles, trailers, etc.
Description (Year, Mileage, Make, Model) Current Fair Purchase/Lease Date Market Value (mmddyyyy) (FMV) Current Loan Balance Amount of Monthly Payment Date of Final Payment (mmddyyyy)

Equity FMV Minus Loan

18a Year Make

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

18b Year Make

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

18c Total Equity (Add lines 18a, 18b and amounts from any attachments) $ Personal Assets. Include all furniture, personal effects, artwork, jewelry, collections (coins, guns, etc.), antiques or other assets.
Purchase/Lease Date Current Fair Market Value (mmddyyyy) (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

19b Property Description $ Location (Street, City, State, ZIP code) and County $ $ $ Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone

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

433-A

(Rev. 1-2008)

Form 433-A (Rev. 1-2008)

Page

If the taxpayer is self-employed, sections 5 and 6 must be completed before continuing.

Monthly Income/Expense Statement (For additional information, refer to Publication 1854.)
Total Income Source Gross Monthly
1

Total Living Expenses Expense Items

5

IRS USE ONLY Actual Monthly Allowable Expenses

20 21 22 23 24 25 26 27 28 29 30 31 32

Wages (Taxpayer) Wages (Spouse)

1

$ $ $ $ $ $ $ $ $ $ $ $ $

33 34 35 36 37 38 39 40 41 42 43 44 45

Food, Clothing, and Misc. Housing and Utilities

7

$ $ $ $ $ $ $ $ $ $ $ $ $

Interest - Dividends Net Business Income 2 Net Rental Income 3 Distributions Pension/Social Security (Taxpayer) Pension/Social Security (Spouse) Child Support Alimony Other (Rent subsidy, Oil credit, etc.) Other Total Income (add lines 20-31)
4

Vehicle Ownership Costs Vehicle Operating Costs Public Transportation Health Insurance
10

Out of Pocket Health Care Costs Court Ordered Payments Child/Dependent Care Life insurance Taxes (Income and FICA) Other Secured Debts (Attach list)

11

Total Living Expenses (add lines 33-44)

1 Wages, salaries, pensions, and social security: Enter gross monthly wages and/or salaries. Do not deduct 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 82. 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 4 5 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. 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. Expenses not generally allowed: We generally do not allow tuition for private schools, public or private college expenses, charitable contributions, voluntary retirement contributions, payments on unsecured debts such as credit card bills, cable television and other similar expenses. However, we may allow these expenses if it is proven that they are necessary for the health and welfare of the individual or family or for the production of income. Food, Clothing, and Misc.: Total of clothing, food, housekeeping supplies, and personal care products for one month. Housing and Utilities: For principal residence: Total of rent or mortgage payment. Add the average monthly expenses for the following: property taxes, home owners or renters insurance, maintenance, dues, fees, and utilities. Utilities include gas, electricity, water, fuel, oil, other fuels, trash collection, telephone, and cell phone. 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.

6 7

8 9

10 Public Transportation: Total of monthly fares for mass transit (e.g., bus, train, ferry, taxi, etc.) 11 Out of Pocket Health Care Costs: Monthly total of medical services, prescription drugs and medical supplies (e.g., eyeglasses, hearing aids, etc.) 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. Taxpayers Signature Spouses Signature Date

Attachments Required for Wage Earners and Self-Employed Individuals: Copies of the following items for the last 3 months from the date this form is submitted (check all attached items): Income - Earnings statements, pay stubs, etc. from each employer, pension/social security/other income, self employment income (commissions, invoices, sales records, etc.). Banks, Investments, and Life Insurance - Statements for all money market, brokerage, checking and savings accounts, certificates of deposit, IRA, stocks/bonds, and life insurance policies with a cash value. Assets - Statements from lenders on loans, monthly payments, payoffs, and balances for all personal and business assets. Include copies of UCC financing statements and accountants depreciation schedules. Expenses - Bills or statements for monthly recurring expenses of utilities, rent, insurance, property taxes, phone and cell phone, insurance premiums, court orders requiring payments (child support, alimony, etc.), other out of pocket expenses. Other - credit card statements, profit and loss statements, all loan payoffs, etc. A copy of last years Form 1040 with all attachments. Include all Schedules K-1 from Form 1120S or Form 1065, as applicable.
Form

433-A

(Rev. 1-2008)

Form 433-A (Rev. 1-2008)

Page

Sections 5 and 6 must be completed only if the taxpayer is SELF-EMPLOYED.

Section 5: Business Information
46 47 Is the business a sole proprietorship (filing Schedule C) Yes, Continue with Sections 5 and 6. No, Complete Form 433-B. All other business entities, including limited liability companies, partnerships or corporations, must complete Form 433-B. Business Name 48 Employer Identification Number 49 Type of Business Federal Contractor 50 Business Website 51 Total Number of Employees 52a Average Gross Monthly Payroll Yes No

52b Frequency of Tax Deposits 53 54a 54b Credit Cards Accepted by the Business.
Credit Card Merchant Account Number Merchant Account Provider, Name & Address (Street, City, State, ZIP code)

Does the business engage in e-Commerce (Internet sales)

Yes

No
Payment Processor Account Number

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

55a 55b 55c 56 Business Cash on Hand. Include cash that is not in a bank. Total Cash on Hand $ Business Bank Accounts. Include checking accounts, online bank 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

57a $ 57b $ 57c Total Cash in Banks (Add lines 57a, 57b 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 Government Contracts.
Accounts/Notes Receivable & Address (Street, City, State, ZIP code) Status (e.g., age, factored, other) Date Due (mmddyyyy) Invoice Number or Federal Government Contract Number Amount Due

58a

$ 58b

$ 58c

$ 58d

$ 58e Total Outstanding Balance (Add lines 58a through 58d and amounts from any attachments)
Form

433-A

(Rev. 1-2008)

Form 433-A (Rev. 1-2008)

Page

Business Assets. Include all tools, books, machinery, equipment, inventory or other assets used in trade or business. Include Uniform Commercial Code (UCC) filings. Include Vehicles and Real Property owned/leased/rented by the business, if not shown in Section 4.
Purchase/Lease/Rental Date (mmddyyyy) Current Fair Market Value (FMV) Current Loan Balance Amount of Monthly Payment Date of Final Payment (mmddyyyy) Equity FMV Minus Loan

59a Property Description $ Location (Street, City, State, ZIP code) and County $ $ $ Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code) and Phone

59b Property Description $ Location (Street, City, State, ZIP code) and County $ $ $ Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code) and Phone

59c Total Equity (Add lines 59a, 59b and amounts from any attachments)

Section 6 should be completed only if the taxpayer is SELF-EMPLOYED

Section 6: Sole Proprietorship Information (lines 60 through 81 should reconcile with business Profit and Loss Statement)
Accounting Method Used: Cash Accrual Income and Expenses during the period (mmddyyyy)
Total Monthly Business Income Source Gross Monthly

to (mmddyyyy)
Expense Items

.
Actual Monthly

Total Monthly Business Expenses (Use attachments as needed.)

1 2

60 61 62 63 64 65 66 67 68 69

Gross Receipts Gross Rental Income Interest Dividends Cash Other Income (Specify below)

$ $ $ $ $ $ $ $ $

70 71 72 73 74 75 76 77 78 79 80

Materials Purchased Inventory Purchased Rent Supplies

3 4

$ $ $ $ $ $ $ $

Gross Wages & Salaries

Utilities/Telephone

Vehicle Gasoline/Oil Repairs & Maintenance

$ Insurance $ Current Taxes 5 Other Expenses, including installment payments (Specify) $ Total Income (Add lines 60 through 68) $ 81 Total Expenses (Add lines 70 through 80) $ 82 Net Business Income (Line 69 minus 81) 6 $ Enter the amount from line 82 on line 23, section 4. If line 82 is a loss, enter 0 on line 23, section 4.
Self-employed taxpayers must return to page 4 to sign the certification and include all applicable attachments.
Current Taxes: Real estate, excise, franchise, occupational, personal property, sales and employers portion of employment taxes.
5 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.

Materials Purchased: Materials are items directly related to the

production of a product or service.

2 3

Inventory Purchased: Goods bought for resale.

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.

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

fuels, trash collection, telephone and cell phone.

FINANCIAL ANALYSIS OF COLLECTION POTENTIAL

FOR INDIVIDUAL WAGE EARNERS AND SELF-EMPLOYED INDIVIDUALS Cash Available (Lines 11, 12c, 13d, 14c, 15g, 56, 57c and 58e) Distrainable Asset Summary (Lines 17c, 18c, 19c, and 59c) Monthly Total Positive Income minus Expenses (Line 32 minus Line 45) Total Cash Total Equity Monthly Available Cash $ $ $

(IRS USE ONLY)

Privacy Act: The information requested on this Form is covered under Privacy Acts and Paperwork Reduction Notices which have already been provided to the taxpayer.
Form

433-A

(Rev. 1-2008)