Instructions
Complete all the blocks. Write N/A (Not Applicable) for
those which don’t apply to you. We need you to complete
the form so we can establish the best method for you to
pay the amount due.
If any section is too small for the information you need to
supply, please use a separate sheet.
Failure to complete the form or provide copies (not
originals) of required attachments (as stated below) may
result in a delay in resolving your account. We may also
require you to submit financial substantiation after our
financial analysis is complete.
Section A – Accounts / Lines of Credit
List all accounts, even if they currently have no balance.
However, do not enter bank loans in this section.
Section B – Real Estate
List all real estate you own or are purchasing. This listing should
include your home and any other real estate you own. Include
the county and description, the year(s) and amount(s) of
purchase and/or refinancing, the current market value and the
amount you owe. To determine equity, subtract the amount
owed from its current market value.
Section C – Other Assets
List all cars, boats, recreational vehicles, whole life policies, or
other assets that you own. If a vehicle is leased, write “lease”
in the “year purchased” column. To determine equity, subtract
the amount owed from its current market value.
Section D – Credit Cards
List all credit cards and lines of credit, even if there is no
balance owed.
Section E – Wage Information
Provide the name and address of employers for you and your
spouse. Include both spouses’ income, even if the tax liability is
not the result of a jointly filed return. Check the appropriate box
indicating how you are paid. Year to Date Income includes all
income, without deductions, for you and your spouse. Include all
wage income from all employers since January of the current
year. Last years gross income should be recorded from last
years filed return.
Se
ctio
n F – Non-Wage Household Income
Enter monthly amounts for all sources of household income. For
any income not received monthly, calculate the monthly amount
as follows:
• If received quarterly - divide by three.
• If received weekly - multiply by 4.3.
• If received biweekly - multiply by 2.17.
Net Self-Employment Income is the amount you earn after you
pay ordinary and necessary monthly business expenses. This
figure should relate to the yearly net profit from Schedule C on
your Form 1040 or your current year profit and loss statement,
but should not include depreciation expenses. If your net income
is less than the previous year, attach an explanation. If net
income is a loss, enter “0”.
Net Rental Income is the amount you earn after you pay
ordinary and necessary monthly rental expenses. This figure
should relate to the amount reported on Schedule E of your
Form 1040 (do not include depreciation expenses). If net rental
income is loss, enter “0”.
Section G – Monthly Necessary Living Expenses
Expenses that do not provide for the health and welfare of you
or your family or for the pr
oduction of income are generally
not considered necessary. These may include tuition for
private schools, public or private college expenses, charitable
contributions, voluntary retirement contributions and payments
to unsecured debts.
Enter monthly amounts for expenses. For any expenses not paid
monthly, calculate the monthly amount as follows:
• If paid quarterly - divide by three.
• If paid weekly - multiply by 4.3.
• If paid biweekly - multiply by 2.17.
For expenses claimed in boxes 1 and 4 you may either use the
total amounts shown on the IRS website at http://www.irs.gov/
individuals/article/0,,id=96543,00.html. Substantiation may be
required once the financial analysis is completed. If you are
currently paying higher expenses you may enter that amount,
but you are also required to submit supporting documentation
with this form, which show payments being made.
For boxes 2 and 3 you must enter only the amount you actually
spend on these expenses. If your total amount is higher than the
amount shown on the IRS website shown above, you are
REQUIRED to submit supporting documentation when submitting
this form, such as copies of cancelled checks etc. which show
payments being made.
All expenses claimed in box 5 REQUIRE supporting documentation
when submitting this form. This includes copies of cancelled
checks, pay stubs etc. that indicate payments are being made.
For any court ordered payments you MUST submit a copy of the
court order portion that shows the amount you are ordered to pay
and the signatures.
If you do not have access to the IRS website, itemize your actual
expenses and we will ask you for additional proof, if required.
Rent - Do not enter mortgage payment here.
Medical - Enter only ongoing medical expenses. Do not include a
one time only medical expense.
Out-of-Pocket health care expenses include:
• Medical services
• Prescription drugs
• Medical supplies, including eyeglasses and contact lenses.
Child / Dependent Care - Enter the monthly amount you pay for
the care of dependents that can be claimed on your Form 1040.
Estimated Tax Payments - Calculate the monthly amount you
pay for estimated taxes by dividing the quarterly amount due on
your Form 1040ES by 3.
Life Insurance - Enter the amount you pay for term life
insurance only. Whole life insurance has cash value and should
be listed in Section C.
Section H – Additional Information
1. The IRS will review your financial information and may
establish a payment agreement for you.
2. Attach signed unfiled returns to this form for processing.
3. Propose a payment amount to be paid:
• In 60-120 days or
• monthly payments in 60 months
4. Show the date you will make your payment each month.
Valid dates are from the 1
st
-28
th
of the month.
5. Show the maximum down payment you can make to lower
the balance due.
Catalog 62053J ZZZLUVJRY
Form
433-F (Rev. 6-2010)
