Fillable Form 433-A (OIC): Collection Information Statement for Wage (IRS)

Fill Online, Printable, Fillable, Blank Form 433-A (OIC): Collection Information Statement for Wage (IRS) Form

Use Fill to complete blank online IRS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 433-A (OIC): Collection Information Statement for Wage (IRS)

On average this form takes 93 minutes to complete

The Form 433-A (OIC): Collection Information Statement for Wage (IRS) form is 8 pages long and contains:

  • 0 signatures
  • 125 check-boxes
  • 312 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your IRS forms online.

The Internal Revenue Service (IRS) is a government agency responsible for collecting taxes and administering the federal statutory tax laws of the United States. The IRS provide tax assistance to taxpayers and pursue and resolve fraudulent tax filings.

BROWSE IRS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Catalog Number 55896Q www.irs.gov
Form
433-A (OIC) (Rev. 4-2021)
Form 433-A (OIC)
(April 2021)
Department of the Treasury — Internal Revenue Service
Collection Information Statement for Wage Earners and
Self-Employed Individuals
Use this form if you are
► An individual who owes income tax on a Form 1040, U.S.
Individual Income Tax Return
► An individual with a personal liability for Excise Tax
► An individual responsible for a Trust Fund Recovery Penalty
► An individual who is self-employed or has self-employment
income. You are considered to be self-employed if you are in
business for yourself, or carry on a trade or business.
► An individual who is personally responsible for a partnership
liability (only if the partnership is submitting an offer)
► An individual who is submitting an offer on behalf of the estate
of a deceased person
Note: Include attachments if additional space is needed to respond completely to any question. This form should only be used with the Form
656, Offer in Compromise.
Section 1 Personal and Household Information
Last name First name
Date of birth (mm/dd/yyyy)
Social Security Number
- -
Marital status
Unmarried Married
If married, date of marriage (mm/dd/yyyy)
Home physical address (street, city, state, ZIP code)
Do you
Own your home Rent
Other (specify e.g., share rent, live with relative, etc.)
County of residence Primary phone
( ) -
Secondary phone
( ) -
FAX number
( ) -
Home mailing address (if different from above or post office box number)
Provide information about your spouse.
Spouse's last name Spouse's first name Date of birth (mm/dd/yyyy)
Provide information for all other persons in the household or claimed as a dependent.
Name Age Relationship
Claimed as a dependent
on your Form 1040
Contributes to
household income
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Social Security Number
- -
Section 2 Employment Information for Wage Earners
Complete this section if you or your spouse are wage earners and receive a Form W-2. If you or your spouse have self-employment income (that is
you file a Schedule C, E, F, etc.) instead of, or in addition to wage income, you must also complete Business Information in Sections 4, 5, and 6.
Your employer’s name Pay period
Weekly Bi-weekly
Monthly Other
Employer’s address (street, city, state, ZIP code)
Do you have an ownership interest in this
business
Yes No
If yes, check the business interest that applies
Partner Sole proprietor
Officer (complete Form 433-B (OIC))
Your occupation How long with this employer
(years) (months)
Spouse’s employer's name Pay period
Weekly Bi-weekly
Monthly Other
Employer’s address (street, city, state, ZIP code)
Does your spouse have an ownership
interest in this business
Yes No
If yes, check the business interest that applies
Partner Sole proprietor
Officer (complete Form 433-B (OIC))
Spouse's occupation How long with this employer
(years) (months)
Catalog Number 55896Q www.irs.gov
Form
433-A (OIC) (Rev. 4-2021)
Page 2
Section 3 Personal Asset Information
Use the most current statement for each type of account, such as checking, savings, money market and online accounts, stored value cards (such as a
payroll card from an employer), investment, retirement accounts (IRAs, Keogh, 401(k) plans, stocks, bonds, mutual funds, certificates of deposit) and virtual currency
(such as Bitcoin, Ripple, Ethereum, etc.)
, life insurance policies that have a cash value, and safe deposit boxes. Asset value is subject to adjustment by IRS
based on individual circumstances. Enter the total amount available for each of the following (if additional space is needed include attachments).
Round to the nearest dollar. Do not enter a negative number. If any line item is a negative number, enter "0".
Cash and Investments (domestic and foreign)
Cash Checking Savings Money Market Account/CD Online Account Stored Value Card
Bank name Account number
(1a) $
Checking Savings Money Market Account/CD Online Account Stored Value Card
Bank name Account number
(1b) $
Total of bank accounts from attachment (1c) $
Add lines (1a) through (1c) minus ($1,000) = (1) $
Investment account Stocks Bonds Other
Name of Financial Institution Account number
Current market value
$ X .8 = $
Minus loan balance
– $
=
(2a) $
Investment account Stocks Bonds Other
Name of Financial Institution Account number
Current market value
$ X .8 = $
Minus loan balance
– $
=
(2b) $
Total investment accounts from attachment. [current market value minus loan balance(s)] (2d) $
Add lines (2a) through (2d) =
(2) $
Virtual currency
Type of virtual currency
Name of virtual currency
wallet, exchange or digital
currency exchange (DCE)
Email address used to
set-up with the virtual
currency exchange or DCE
Location(s) of virtual
currency
$
=
X .8 = $
=
Current market value in U.S. dollars as of today
(2c) $
Retirement account 401K IRA Other
Name of Financial Institution Account number
Current market value
$ X .8 = $
Minus loan balance
– $
=
(3a) $
Total of retirement accounts from attachment. [current market value X .8 minus loan balance(s)] (3b) $
Add lines (3a) through (3b) = (3) $
Note: Your reduction from current market value may be greater than 20% due to potential tax consequences/withdrawal penalties.
Cash value of Life Insurance Policies
Name of Insurance Company Policy number
Current cash value
$
Minus loan balance
– $
=
(4a) $
Total cash value of life insurance policies from attachment
$
Minus loan balance(s)
– $
=
(4b) $
Add lines (4a) through (4b) = (4) $
Catalog Number 55896Q www.irs.gov
Form
433-A (OIC) (Rev. 4-2021)
Page 3
Section 3 (Continued) Personal Asset Information
Real property (enter information about any house, condo, co-op, time share, etc. that you own or are buying including any assets owned by
your spouse if you live in a community property state)
Is your real property currently for sale or do you anticipate selling your real property to fund the offer amount
Yes
(listing price)
No
Property description (indicate if personal residence, rental property, vacant, etc.) Purchase date (mm/dd/yyyy)
Amount of mortgage payment Date of final payment How title is held (joint tenancy, etc.)
Location (street, city, state, ZIP code, county, and country) Lender/Contract holder name, address (street, city,
state, ZIP code)
and phone
Current market value
$ X .8 = $
Minus loan balance (mortgages, etc.)
– $
(total value of real estate) = (5a) $
Property description (indicate if personal residence, rental property, vacant, etc.) Purchase date (mm/dd/yyyy)
Amount of mortgage payment Date of final payment How title is held (joint tenancy, etc.)
Location (street, city, state, ZIP code, county, and country) Lender/Contract holder name, address (street, city,
state, ZIP code)
and phone
Current market value
$ X .8 = $
Minus loan balance (mortgages, etc.)
– $
(total value of real estate) = (5b) $
Total value of property(s) from attachment [current market value X .8 minus any loan balance(s)] (5c) $
Add lines (5a) through (5c) = (5) $
Vehicles (enter information about any cars, boats, motorcycles, etc. that you own or lease)
Vehicle make & model Year Date purchased Mileage
Lease
Loan
Name of creditor Date of final payment Monthly lease/loan amount
$
Current market value
$ X .8 = $
Minus loan balance
– $
Total value of vehicle (if the vehicle
is leased, enter 0 as the total value)
=
(6a) $
Subtract $3,450 from line (6a)
(If line (6a) minus $3,450 is a negative number, enter "0")
(6b) $
Vehicle make & model Year Date purchased Mileage
Lease
Loan
Name of creditor Date of final payment Monthly lease/loan amount
$
Current market value
$ X .8 = $
Minus loan balance
– $
Total value of vehicle (if the vehicle
is leased, enter 0 as the total value)
=
(6c) $
If you are filing a joint offer, subtract $3,450 from line (6c)
(If line (6c) minus $3,450 is a negative number, enter "0")
If you are not filing a joint offer, enter the amount from line (6c)
(6d) $
Total value of vehicles listed from attachment [current market value X .8 minus any loan balance(s)] (6e) $
Total lines (6b), (6d), and (6e) = (6) $
Catalog Number 55896Q www.irs.gov
Form
433-A (OIC) (Rev. 4-2021)
Page 4
Section 3 (Continued) Personal Asset Information
Other valuable items (artwork, collections, jewelry, items of value in safe deposit boxes, interest in a company or business that is not publicly traded, etc.)
Description of asset(s)
Current market value
$ X .8 = $
Minus loan balance
– $
=
(7a) $
Value of remaining furniture and personal effects (not listed above)
Description of asset
Current market value
$ X .8 = $
Minus loan balance
– $
=
(7b) $
Total value of valuable items listed from attachment [current market value X .8 minus any loan balance(s)] (7c) $
Add lines (7a) through (7c) minus IRS deduction of $9,790 = (7) $
Do not include amount on the lines with a letter beside the number. Round to the nearest whole dollar.
Do not enter a negative number. If any line item is a negative, enter "0" on that line.
Add lines (1) through (7) and enter the amount in Box A =
Box A
Available Individual Equity in Assets
$
NOTE: If you or your spouse are self-employed, Sections 4, 5, and 6 must be completed before continuing with Sections 7 and 8.
Section 4 Self-Employed Information
If you or your spouse are self-employed (e.g., files Schedule(s) C, E, F, etc.), complete this section.
Is your business a sole proprietorship
Yes No
Name of business
Address of business (if other than personal residence)
Business telephone number
( ) -
Employer Identification Number Business website address Trade name or DBA
Description of business Total number of employees Frequency of tax deposits Average gross monthly
payroll $
Do you or your spouse have any other business interests? Include any
interest in an LLC, LLP, corporation, partnership, etc.
Yes
(percentage of ownership: )
Title
No
Business address (street, city, state, ZIP code)
Business name
Business telephone number
( ) -
Employer Identification Number
Type of business (select one)
Partnership LLC Corporation Other
Section 5 Business Asset Information (for Self-Employed)
List business assets such as bank accounts, virtual currency (cryptocurrency), tools, books, machinery, equipment, business vehicles and real property
that is owned/leased/rented. If additional space is needed, attach a list of items. Do not include personal assets listed in Section 3.
Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative number, enter "0".
Cash Checking Savings Money Market Account/CD Online Account Stored Value Card
Bank name Account number
(8a) $
Cash Checking Savings Money Market Account/CD Online Account Stored Value Card
Bank name Account number
(8b) $
Total bank accounts from attachment (8d) $
Add lines (8a) through (8d) = (8) $
Virtual currency
Type of virtual currency
Name of virtual currency
wallet, exchange or digital
currency exchange (DCE)
Email address used to
set-up with the virtual
currency exchange or DCE
Location(s) of virtual
currency
$
=
X .8 = $
=
Current market value in U.S. dollars as of today
(8c) $
Catalog Number 55896Q www.irs.gov
Form
433-A (OIC) (Rev. 4-2021)
Page 5
Section 5 (Continued) Business Asset Information (for Self-Employed)
Description of asset
Current market value
$ X .8 = $
Minus loan balance
– $
Total value (if leased or used
in the production of income,
enter 0 as the total value)
=
(9a) $
Description of asset:
Current market value
$ X .8 = $
Minus Loan Balance
– $
Total value (if leased or used
in the production of income,
enter 0 as the total value)
=
(9b) $
Total value of assets listed from attachment [current market value X .8 minus any loan balance(s)] (9c) $
Add lines (9a) through (9c) = (9) $
IRS allowed deduction for professional books and tools of trade – (10) $
Enter the value of line (9) minus line (10). If less than zero enter zero. = (11) $
Notes Receivable
Do you have notes receivable Yes No
If yes, attach current listing that includes name(s) and amount of note(s) receivable
Accounts Receivable
Do you have accounts receivable, including e-payment, factoring
companies, and any bartering or online auction accounts
Yes No
If yes, provide a list of your current accounts receivable
Do not include amounts from the lines with a letter beside the number [for example: (9c)].
Round to the nearest whole dollar.
Do not enter a negative number. If any line item is a negative, enter "0" on that line.
Add lines (8) and (11) and enter the amount in Box B =
Box B
Available Business Equity in
Assets
$
Section 6 Business Income and Expense Information (for Self-Employed)
If you provide a current profit and loss (P&L) statement for the information below, enter the total gross monthly income on line 17 and your monthly
expenses on line 29 below. Do not complete lines (12) - (16) and (18) - (28). You may use the amounts claimed for income and expenses on your most
recent Schedule C; however, if the amount has changed significantly within the past year, a current P&L should be submitted to substantiate the claim.
Period provided beginning through
Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative number, enter "0".
Business income (you may average 6-12 months income/receipts to determine your gross monthly income/receipts)
Gross receipts (12) $
Gross rental income (13) $
Interest income (14) $
Dividends (15) $
Other income (16) $
Add lines (12) through (16) = (17) $
Business expenses (you may average 6-12 months expenses to determine your average expenses)
Materials purchased (e.g., items directly related to the production of a product or service) (18) $
Inventory purchased (e.g., goods bought for resale) (19) $
Gross wages and salaries (20) $
Rent (21) $
Supplies (items used to conduct business and used up within one year, e.g., books, office supplies, professional equipment, etc.) (22) $
Utilities/telephones (23) $
Vehicle costs (gas, oil, repairs, maintenance) (24) $
Business insurance (25) $
Current business taxes (e.g., real estate, excise, franchise, occupational, personal property, sales and employer's portion of
employment taxes)
(26) $
Secured debts (not credit cards) (27) $
Other business expenses (include a list) (28) $
Add lines (18) through (28) = (29) $
Round to the nearest whole dollar.
Do not enter a negative number. If any line item is a negative, enter "0" on that line.
Subtract line (29) from line (17) and enter the amount in Box C =
Box C
Net Business Income
$
Catalog Number 55896Q www.irs.gov
Form
433-A (OIC) (Rev. 4-2021)
Page 6
Section 7 Monthly Household Income and Expense Information
Enter your household's gross monthly income. Gross monthly income includes wages, social security, pension, unemployment, and other income.
Examples of other income include but are not limited to: agricultural subsidies, gambling income, oil credits, rent subsidies, Uber & Lyft driver income,
and Airbnb rentals etc. The information below is for yourself, your spouse, and anyone else who contributes to your household's income. The entire
household includes spouse, non-liable spouse, significant other, children, and others who contribute to the household. This is necessary for the IRS to
accurately evaluate your offer.
Monthly Household Income
Note: Entire household income should also include income that is considered not taxable and may not be included on your tax return.
Round to the nearest whole dollar.
Primary taxpayer
Gross wages
$
Social Security
+ $
Pension(s)
+ $
Other income (e.g. unemployment)
+ $
Total primary
taxpayer income =
(30) $
Spouse
Gross wages
$
Social Security
+ $
Pension(s)
+ $
Other Income (e.g. unemployment)
+ $
Total spouse
income =
(31) $
(32) $
Distributions (e.g., income from partnerships, sub-S Corporations, etc.) (34) $
Net rental income (35) $
Net business income from Box C (36) $
Child support received (37) $
Alimony received (38) $
Round to the nearest whole dollar.
Do not enter a negative number. If any line item is a negative, enter "0" on that line.
Add lines (30) through (38) and enter the amount in Box D =
Box D
Total Household Income
$
Food, clothing, and miscellaneous (e.g., housekeeping supplies, personal care products , minimum payment on credit card).
A reasonable estimate of these expenses may be used
(39) $
Housing and utilities (e.g., rent or mortgage payment and average monthly cost of property taxes, home insurance,
maintenance, dues, fees and utilities including electricity, gas, other fuels, trash collection, water, cable television and internet,
telephone, and cell phone)
monthly rent payment
(40) $
Vehicle loan and/or lease payment(s) (41) $
Vehicle operating costs (e.g., average monthly cost of maintenance, repairs, insurance, fuel, registrations, licenses,
inspections, parking, tolls, etc.)
. A reasonable estimate of these expenses may be used
(42) $
Public transportation costs (e.g., average monthly cost of fares for mass transit such as bus, train, ferry, taxi, etc.). A
reasonable estimate of these expenses may be used (43) $
Health insurance premiums (44) $
Out-of-pocket health care costs (e.g. average monthly cost of prescription drugs, medical services, and medical supplies like
eyeglasses, hearing aids, etc.)
(45) $
Court-ordered payments (e.g., monthly cost of any alimony, child support, etc.) (46) $
Child/dependent care payments (e.g., daycare, etc.) (47) $
Life insurance premiums (48) $
Current monthly taxes (e.g., monthly cost of federal, state, and local tax, personal property tax, etc.) (49) $
Interest, dividends, and royalties (33) $
Additional sources of income used to support the household, e.g., non-liable spouse, or anyone else who may
contribute to the household income, etc.
List source(s)
(50) $
Enter the amount of your monthly delinquent state and/or local tax payment(s)
. Total tax owed
(51) $
Round to the nearest whole dollar.
Do not enter a negative number. If any line item is a negative, enter "0" on that line.
Add lines (39) through (51) and enter the amount in Box E =
Secured debts/Other (e.g., any loan where you pledged an asset as collateral not previously listed, government guaranteed
student loan, employer required retirement or dues)
List debt(s)/expense(s)
Box E
Total Household Expenses
$
Round to the nearest whole dollar.
Do not enter a negative number. If any line item is a negative, enter "0" on that line.
Subtract Box E from Box D and enter the amount in Box F =
Box F
Remaining Monthly Income
$
Monthly Household Expenses
Enter your average monthly expenses.
Note: For expenses claimed in boxes (39) and (45) only, you should list the full amount of the allowable standard even if the
actual amount you pay is less. For the other boxes input your actual expenses. You may find the allowable standards at
http://www.irs.gov/Businesses/Small-Businesses-&-Self-Employed/Collection-Financial-Standards.
Round to the nearest whole dollar.
Catalog Number 55896Q www.irs.gov
Form
433-A (OIC) (Rev. 4-2021)
Page 7
Section 8 Calculate Your Minimum Offer Amount
If you will pay your offer in 5 or fewer payments within 5 months or less, multiply "Remaining Monthly Income" (Box F) by 12 to get "Future Remaining
Income" (Box G). Do not enter a number less than $0.
Enter the total from Box F
$
X 12 =
Box G Future Remaining Income
$
If you will pay your offer in 6 to 24 months, multiply "Remaining Monthly Income" (Box F) by 24 to get "Future Remaining Income" (Box H). Do not enter
a number less than $0.
Enter the total from Box F
$
X 24 =
Box H Future Remaining Income
$
Determine your minimum offer amount by adding the total available assets from Box A and Box B (if applicable) to the amount in either Box G or Box H.
Enter the amount from Box A
plus Box B (if applicable)
$
+
Enter the amount from either
Box G or Box H
$
=
Offer Amount
Your offer must be more than zero ($0). Do
not leave blank. Use whole dollars only.
$
If you cannot pay the Offer Amount shown above due to special circumstances, explain on the Form 656, Offer in
Compromise, Section 3, Reason for Offer, Explanation of Circumstances. You must offer an amount more than
$0.
Section 9 Other Information
Additional information IRS needs to consider settlement of your tax debt. If you or your business are currently in a bankruptcy proceeding,
you are not eligible to apply for an offer.
Have you filed bankruptcy in the past 7 years (if yes, answer the following)
Yes No
Date filed (mmddyyyy)
Date dismissed (mmddyyyy) Date discharged (mmddyyyy)
Petition no. Location filed
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)
Are you a party to or involved in litigation (if yes, answer the following) Yes No
Defendant
Plaintiff
Location of filing Docket/Case numberRepresented by
Possible completion date (mmddyyyy) Subject of litigation
$
Amount of dispute
If yes and the litigation included tax debt, provide the types of tax and periods involved
NoYesAre you or have you ever been party to any litigation involving the IRS/United States (including any tax litigation)
Are you a trustee, fiduciary, or contributor of a trust Yes No
EIN
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
$
Name of the trust
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
The next steps calculate your minimum offer amount. The amount of time you take to pay your offer in full will affect your minimum offer amount. Paying
over a shorter period of time will result in a smaller minimum offer amount.
Note: The multipliers below (12 and 24) and the calculated offer amount (which included the amount(s) allowed for vehicles and bank
accounts) do not apply if the IRS determines you have the ability to pay your tax debt in full within the legal period to collect.
Round to the nearest whole dollar.
Yes No
List asset(s)
Value at time of transfer
$
Date transferred (mmddyyyy)
To whom or where was it transferred
In the past 10 years, have you transferred any assets, including real property, for less than their full value (if yes, answer the
following)
Catalog Number 55896Q www.irs.gov
Form
433-A (OIC) (Rev. 4-2021)
Page 8
Section 9 (Continued) Other Information
Do you have any assets or own any real property outside the U.S. Yes No
If yes, provide description, location, and value
Do you have any funds being held in trust by a third party Yes No
If yes, how much $ Where
Section 10 Signatures
Under penalties of perjury, I declare that I have examined this offer, including accompanying documents, and to the best of my knowledge it
is true, correct, and complete.
►
Signature of Taxpayer
Date (mm/dd/yyyy)
►
Signature of Spouse
Date (mm/dd/yyyy)
Remember to include all applicable attachments listed below.
Copies of the most recent pay stub, earnings statement, etc., from each employer.
Copies of the most recent statement for each investment and retirement account.
Copies of the most recent statement, etc., from all other sources of income such as pensions, Social Security, rental income,
interest and dividends (including any received from a related partnership, corporation, LLC, LLP, etc.), court order for child
support, alimony, royalties, and rent subsidies.
Copies of individual complete bank statements for the three most recent months. If you operate a business, copies of the six
most recent complete statements for each business bank account.
Copies of the most recent statement from lender(s) on loans such as mortgages, second mortgages, vehicles, etc., showing
monthly payments, loan payoffs, and balances.
List of Accounts Receivable or Notes Receivable, if applicable.
Verification of delinquent State/Local Tax Liability showing total delinquent state/local taxes and amount of monthly payments, if
applicable.
Copies of court orders for child support/alimony payments claimed in monthly expense section.
Copies of Trust documents if applicable per Section 9.
Documentation to support any special circumstances described in the “Explanation of Circumstances” on Form 656, if applicable.
Attach a Form 2848, Power of Attorney, if you would like your attorney, CPA, or enrolled agent to represent you and you do not
have a current form on file with the IRS. Make sure the current tax year is included.
Completed and signed current Form 656.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 433-A (OIC): Collection Information Statement for Wage (IRS)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document