Collection Information Statement for Wage Earners and Self-Employed Individuals

Complete all entry spaces with the most current data available.
Important! Write “N/A” (not applicable) in spaces that do not apply. We may require additional information

www.irs.gov

to support “N/A” entries.

Form 433-A (Rev. 5-2001) Catalog Number 20312N

Failure to complete all entry spaces may result in rejection or significant delay in the resolution of your account.

Section 1

1. Full Name(s)

1a. Home

Best Time To Call:

Personal

Telephone (	)

am

pm

Information

Street Address

(Enter Hour)

2. Marital Status:

City

State

Zip

Married

Separated

County of Residence

How long at this address?

Unmarried (single, divorced, widowed)

3. Your Social Security No.(SSN)

3a. Your Date of Birth (mm/dd/yyyy)

4. Spouse’s Social Security No.

4a. Spouse’s Date of Birth (mm/dd/yyyy)

5.

Own Home

Rent

Other (specify, i.e. share rent, live with relative)

6. List the dependents you can claim on your tax return: (Attach sheet if more space is needed.)

First Name	Relationship Age

Does this person

First Name	Relationship

Age

Does this person

live with

live with you?

Check this box

No

Yes

No

Yes

when all spaces in

Sect. 1 are filled in.

No

Yes

No

Yes

Section 2

7. Are you or your spouse self-employed or operate a business? (Check “Yes” if either applies)

Your

No

Yes If yes, provide the following information:

Business

7a. Name of Business

7c. Employer Identification No., if available :

Information

7b. Street Address

7d. Do you have employees?

No

Yes

City

State

Zip

7e. Do you have accounts/notes receivable?

No

Yes

Check this box

If yes, please complete Section 8 on page 5.

when all spaces in

Sect. 2 are filled in

ATTACHMENTS REQUIRED: Please include proof of self-employment income for the prior 3 months (e.g., invoices, commissions, sales records, income statement).

and attachments

provided.

Section 3

8. Your Employer

9. Spouse’s Employer

Street Address

Street Address

Employment

Information

City

State

Zip

City

State

Zip

Work telephone no.

Work telephone no

May we contact you at work?

No

Yes

May we contact you at work?

No

Yes

8a. How long with this employer?

9a. How long with this employer?

8b. Occupation

9b. Occupation

Check this box

when all spaces in

ATTACHMENTS REQUIRED: Please provide proof of gross earnings and deductions for the past 3 months from each employer (e.g., pay stubs, earnings statements). If year-to-date information is available, send only 1 such statement as long as a minimum of 3 months is represented.

Sect. 3 are filled in

and attachments

provided.

Section 4

10. Do you receive income from sources other than your own business or your employer? (Check all that apply.)

Other

Income

Pension

Social Security

Other (specify, i.e. child support, alimony, rental)

Information

Check this box

when all spaces in

ATTACHMENTS REQUIRED: Please provide proof of pension/social security/other income for the past 3 months from each payor, including any statements showing deductions. If year-to-date information is available, send only 1 such statement as long as a minimum of 3 months is represented.

Sect. 4 are filled in

and attachments

provided.

Page 1 of 6

Section 5 begins on page 2

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

Banking,

Investment,

and Life

Insurance

Information

Complete all

entry spaces

with the most

current data

available.

:() Current

Value:

Indicate the

amount you

could sell the

asset for

today.

Section 5 11. CHECKING ACCOUNTS. List all checking accounts. (If you need additional space, attach a separate sheet.)

Type of

Full Name of Bank, Savings & Loan, Credit Union or Financial Institution

Bank

Bank

Current

Account

Routing No.

Account No.

Account Balance

Cash, Credit, 11a. Checking

Name

$

Street Address

City/State/Zip

11b. Checking

Name

$

Street Address

City/State/Zip

11 c. Total Checking Account Balances

$

12. OTHER ACCOUNTS. List all acounts, including brokerage, savings, and money market, not listed on line 11.

Type of

Full Name of Bank, Savings & Loan, Credit Union or Financial Institution

Bank

Bank

Current

Account

Routing No.

Account No.

Account Balance

12a.

Name

$

Street Address

City/State/Zip

12b.

Name

$

Street Address

City/State/Zip

12c. Total Other Account Balances

$

ATTACHMENTS REQUIRED: Please include your current bank statements (checking, savings, money market, and brokerage accounts) for the past three months for all accounts.

13. INVESTMENTS. List all investment assets below. Include stocks, bonds, mutual funds, stock options, certificates of deposits, and retirement assets such as IRAs, Keogh, and 401(k) plans. (If you need additional space, attach a separate sheet.)

Name of Company

Shares / Units

Number of

:()Current

Value

Amount

Loan

on loan?

Used as collateral

13a.

$

$

No

Yes

13b.

No

Yes

13c.

No

Yes

13d. Total Investments

$

14. CASH ON HAND. Include any money that you have that is not in the bank.

14a. Total Cash on Hand

$

15. AVAILABLE CREDIT. List all lines of credit, including credit cards.

Full Name of

Credit Institution

Credit Limit

Amount Owed

Available Credit

15a. Name

$

Street Address

City/State/Zip

15b. Name

$

Street Address

City/State/Zip

15c. Total Credit Available	$

Page 2 of 6

Section 5 continued on page 3

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

Section 5

continued

Check this box

when all spaces in

Sect. 5 are filled in

and attachments

provided.

16. LIFE INSURANCE. Do you have life insurance with a cash value?

No

Yes

(Term Life insurance does not have a cash value.)

If yes:

16a. Name of Insurance Company

16b. Policy Number(s)

16c. Owner of Policy

16d. Current Cash Value $

16e. Outstanding Loan Balance $

Subtract “Outstanding Loan Balance“ line 16e from “Current Cash Value” line 16d = 16f $

ATTACHMENTS REQUIRED: Please include a statement from the life insurance companies that includes type and cash/loan value amounts. If currently borrowed against, include loan amount and date of loan.

Section 6

Other

Information

Check this box

Sect. 6 are filled in.

17. OTHER INFORMATION. Respond to the following questions related to your financial condition: (Attach sheet if you need more space.)

17a. Are there any garnishments against your wages?

No

Yes

If yes, who is the creditor?

Date creditor obtained judgement

Amount of debt $

17b. Are there any judgments against you?

No

Yes

If yes, who is the creditor?

Date creditor obtained judgement

Amount of debt $

17c. Are you a party in a lawsuit?
If yes, amount of suit $

No

Yes

Possible completion date

Subject matter of suit

17d. Did you ever file bankruptcy?

No

Yes

If yes, date filed

Date discharged

17e. In the past 10 years did you transfer any
name for less than

their actual va

assets out

of lyuoeu?r

No

Yes

If yes, what asset?

Value of asset at time of transfer $

When was it transferred?

To whom was it transferred?

17f. Do you anticipate any increase in household

income in the next two years?

No

Yes

If yes, why will the income increase?

(Attach sheet if you need more space.)

How much will it increase? $

17g. Are you a beneficiary of a trust or an estate?

No

Yes

If yes, name of the trust or estate

Anticipated amount to be received $

When will the amount be received?

when all spaces in 17h. Are you a participant in a profit sharing plan?

No

Yes

If yes, name of plan

Value in plan $

Section 7

Assets and

Liabilities

() Current

Value:

Indicate the

amount you

could sell the

asset for

today.

18. PURCHASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)

Description

()C urrent

Current

Name of

Purchase

Amount of

Monthly

(Year, Make, Model, Mileage)

Value

Loan

Balance

Lender

Date

Payment

18a. Year

Make/Model

Mileage

$

$

18b. Year

Make/Model

Mileage

$

$

$

18c. Year

Make/Model

Mileage

$

$

$

Page 3 of 6

Section 7 continued on page 4

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

continued

:() Current

Value:

Indicate the

amount you

could sell the

asset for

today.

* Date of

Final Pay‑

ment:

Enter the date

the loan or

lease will be

fully paid.

provided.

Section 7 19. LEASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)

Name and

Amount of

Description

(Year, Make, Model)

Lease

Balance

Address of

Lessor

Lease

Date

Monthly

Payment

19a. Year

Make/Model

$

$

19b. Year

Make/Model

$

$

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly car payment amount and current balance of the loan for each vehicle purchased or leased.

20. REAL ESTATE. List all real estate you own. (If you need additional space, attach a separate sheet.)

Amount of

*Date

Street Address, City, State, Zip, and County

Date

Purchase

:()Current

Loan

Name of Lender

Monthly

of Final

Purchased Price

Value

Balance

or Lien Holder

Payment

Payment

20a.

$

$

$

$

20b.

$

$

$

$

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly payment amount and current balance for each piece of real estate owned.

21. PERSONAL ASSETS. List all Personal assets below. (If you need additional space, attach separate sheet.)

Furniture/Personal Effects includes the total current market value of your household such as furniture and appliances. Other Personal Assets includes all artwork, jewelry, collections (coin/gun, etc.), antiques or other assets.

Amount of

 Date of

:()Current

Loan

Monthly

Final

Description

Value

Balance

Name of Lender

Payment

Payment

21a. Furniture/Personal Effects

$

$

$

Other: (List below)

21 b. Artwork

$

$

$

21c. Jewelry

21 d.

21e.

22. BUSINESS ASSETS. List all business assets and encumbrances below, include Uniform Commercial Code (UCC) filings. (If

you need additional space, attach a separate sheet.) Tools used in Trade or Business includes the basic tools or books used to conduct your business, excluding automobiles. Other Business Assets includes any other machinery, equipment, inventory or other assets.

Amount of

 Date of

:()Current

Loan

Monthly

Final

Description

Value

Balance

Name of Lender

Payment

Payment

22a. Tools used in Trade/Business $

$

$

Other: (List below)

22b. Machinery

$

$

$

Check this box 22c. Equipment

when all spaces in

Sect. 7 are filled in 22d.

and attachments 22e.

Page 4 of 6

Section 8 begins on page 5

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

Use only if

needed.

Check this

8 not needed.

Check this box

when all spaces in

Sect. 8 are filled in.

Section 8 23. ACCOUNTS/NOTES RECEIVABLE. List all accounts separately, including contracts awarded, but not Accounts/
Notes
Receivable

started. (If you need additional space, attach a separate sheet.)

Description

Amount Due

Date Due

Age of Account

$

0 - 30 days

23a. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

box if Section23b. Name

$

0 - 30 days

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

23c. Name

$

0 - 30 days

Street Address

30 - 60 days

City/State/Zip

60 - 90 days

90+ days

$

0 - 30 days

23d. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23e. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23f. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

23g. Name

$

0 - 30 days

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23h. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23i. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23j. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

23k. Name

$

0 - 30 days

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

$

0 - 30 days

23l. Name

30 - 60 days

Street Address

60 - 90 days

City/State/Zip

90+ days

Add “Amount Due” from lines 23a through 23l = 23m $

Page 5 of 6

Section 9 begins on page 6

(Rev. 5-2001)

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Collection Information Statement for Wage Earners and Self-Employed Individuals

Form 433-A

Name

SSN

Section 9 Total Income

Total Living Expenses

Monthly

Source

Gross Monthly

Expense Items 4

Actual Monthly

Income and 24. Wages (Yourself)'

$

35. Food, Clothing and Misc.5

$

36. Housing and Utilities6

Expense

25. Wages (Spouse)'

Analysis

26. Interest - Dividends

37. Transportation7

27. Net Income from Business2

38. Health Care

If only one

28. Net Rental Income3

39. Taxes (Income and FICA)

spouse has a

tax liability, but 29. Pension/Social Security (Yourself)

40. Court ordered payments

both have

30. Pension/Social Security (Spouse)

41. Child/dependent care

income, list the 3'. Child Support

42. Life insurance

total household 32. Alimony

43. Other secured debt

income and

33. Other

44. Other expenses

expenses.

34. Total Income

$

45. Total Living Expenses

$

' Wages, salaries, pensions, and social security: Enter your gross monthly wages and/or salaries. Do not deduct withholding or allotments you elect to take out of your pay, such as insurance payments, credit union deductions, car payments etc.

To calculate your 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 bi-weekly (every 2 weeks) - multiply bi-weekly gross wages by 2.17. Example: $972.45 x 2.17 = $2,110.22
If paid semi-monthly (twice each month) - multiply semi-monthly gross wages by 2. Example: $856.23 x 2 = $1,712.46

2 Net Income from Business: Enter your monthly net business income. This is the amount you earn after you pay ordinary and necessary monthly business expenses. This figure should relate to the yearly net profit from your Form 1040 Schedule C. If it is more or less than the previous year, you should attach an explanation. If your net business income is a loss, enter “0”. Do not enter a negative number.

3 Net Rental Income: Enter your monthly net rental income. This is the amount you earn after you pay ordinary and necessary monthly rental expenses. If your net rental income is a loss, enter “0”. Do not enter a negative number.

4 Expenses not generally allowed: We generally do not allow you to claim 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 you can prove that they are necessary for the health and welfare of you or your family or for the production of income.

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

6 Housing and Utilities: For your principal residence: Total of rent or mortgage payment. Add the average monthly expenses for the following: property taxes, home owner’s or renter’s insurance, maintenance, dues, fees, and utilities. Utilities include gas, electricity, water, fuel, oil, other fuels, trash collection and telephone.

7 Transportation: Total of lease or purchase payments, vehicle insurance, registration fees, normal maintenance, fuel, public transportation, parking and tolls for one month.

ATTACHMENTS REQUIRED: Please include:
•	A copy of your last Form 1040 with all Schedules.

•	Proof of all current expenses that you paid for the past 3 months, including utilities, rent, insurance, property taxes, etc.

•	Proof of all non-business transportation expenses (e.g., car payments, lease payments, fuel, oil, insurance, parking, registration).

Check this

•	Proof of payments for health care, including health insurance premiums, co-payments, and other out-of-pocket expenses, for the past 3 months.

box when all

• Copies of any court order requiring payment and proof of such payments (e.g., cancelled checks, money orders, earning statements showing such deductions) for the past 3 months.

spaces in Sect. 9

are filled in and

attachments

provided.

Check this box

when all spaces in

Failure to complete all entry spaces may result in rejection or significant delay in the resolution of your

all sections are

filled in and all

account.

attachments

provided.

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.

Your Signature

Spouse’s Signature

Date

Page 6 of 6

(Rev. 5-2001)

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