Fillable Form 433A: West Virginia State Tax Department (State of West Virginia)

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Form 433A: West Virginia State Tax Department (State of West Virginia)

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The Form 433A: West Virginia State Tax Department (State of West Virginia) form is 4 pages long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for State of West Virginia

BROWSE STATE OF WEST VIRGINIA (WV) FORMS

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2. Home phone number
( )
3. Marital status
1. Taxpayer(s) name and address
County ________
4a. Taxpayer's SS No.
b. Spouse's social security no.
Section I. Employment Information
a. How long employed
Business phone Number
( )
c. Occupation
5. Taxpayer's employer or business
(name and address)
d. Number of exemptions
claimed on Form W-4
_______
e. Pay period
Weekly Bi-weekly
Monthly _________
Payday: ________ (Mon - Sun)
f. (Check appropriate
box)
Wage earner
Sole proprietor
Partner
a. How long employed
b. Business phone number
( )
c. Occupation
6. Spouse's employer or business
(name and address)
d. Number of exemptions
claimed on Form W-4
______
e. Pay period
Weekly Bi-weekly
Monthly _________
Payday: ________ (Mon - Sun)
f. (Check appropriate
box)
Wage earner
Sole proprietor
Partner
SECTION II.
Personal Information
7. Name, address and telephone number of next of kin or
other reference
8. Other names or aliases
9. Previous address(es)
10. Age and relationship of dependents living in your household (exclude yourself and spouse)
a. Taxpayer
11.
Date
of
Birth
b. Spouse
12. Latest filed income tax
return (tax year)
a. No. of
exemptions
claimed
b. Adjusted Gross
Income
Section III. General Financial Information
13. Bank accounts (include savings & loans, credit unions, IRA and retirement plans, certificates of deposit, etc.) Enter bank loans in item 28.
Name of Institution
Address
Type of Acct.
Acct. #
Balance
Total
(Enter in Item 21)
$
West Virginia State Tax Department
Collection Information Statement For Individuals
(If you need additional space, please attach a separate sheet)
Complete all blocks, except shaded areas. Write “N/A” (non applicable) in those blocks that do not apply.
Form 433A
(
Rev. Nov. 07)
Reset Form
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Section III. - continued General Financial Information
14. Charge cards and lines of credit from banks, credit unions, and savings and loans. List all other charge accounts in item 28.
Type of Account
or Card
Name and Address of
Financial Institution
Monthly
Payment
Credit
Limit
Amount
Owed
Credit Available
Totals (Enter in Items 27)
15. Safe deposit boxes rented or accessed (List all locations, box numbers, and contents)
16. Real Property (Brief description and type of ownership)
Physical Address
a.
County
_________
b.
County _________
c.
County _________
17.Life insurance (Name of Company)
Policy
Number
Type
Face
Amount
Available Loan
Value
Whole
Term
Whole
Term
Whole
Term
Total
(Enter in Item 23)
$
18. Securities (stocks, bonds, mutual funds, money market funds, government securities, etc.):
Kind
Quantity or
Denomination
Current
Value
Where
Located
Owner
of Record
19. Other information relating to your financial conditions. If you check the yes box below , please give dates and explain on page 4,
Additional information or Comments:
a
. Court proceedings Yes No
b. Bankruptcies Yes No
c. Repossessions Yes No
d. Recent sale or other transfer Yes No
of assets for less than full value
0.00
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0.00
0.00
Section IV. Asset and Liabilities
Description
Current
Market
Value
Current
Amount
Owed
Equity in
Asset
Amt. of
Mo.
Payment
Name and Address of
Lien / Note Holder /
Obligee / Lender
Date
Pledged
Date of
Final
Pymt
2
0. Cash
21. Bank Accounts (from
Item 13)
22. Securities (from Item 18)
23. Cash or loan value of
insurance
24. Vehicles (model, year,
license, tag#)
a.
b.
c.
a.
b.
25. Real
Property (From
Section III, Item
16)
c.
26. Other assets
a.
b.
c.
d
e.
27. Bank revolving credit
(from item 14)
28. Other liabilities (i.e. bank loans, judgments, notes and charge accounts not entered in Item 13)
a.
b.
c.
d.
e.
f.
g.
29. State taxes owed (prior
year)
30. Totals
$
$
0.00
0.00
0.00
0.00
0.00
0.00
Section V. Monthly Income and Expense Analysis
Total Income
Necessary Living Expenses
Source
Gross
Claimed
(State use only)
Allowed
31. Wages / Salaries (Taxpayer)
$
42. Housing and utilities
$
32. Wages / Salaries (Spouse)
43. Transportation
33. Interest – Dividends
44. Health Care
34. Net Business Income (Form 433-B)
45. Taxes (Income and FICA)
35. Rental Income
46. Court ordered payments
36. Pension (Taxpayer)
47. Child / dependent care
37. Pension (Spouse)
48. Life insurance
38. Child Support
49. Other expenses (specify)
39. Alimony
40. Other
41. Total Income
$
50. Total Expenses
$
$
51. Net differences
(State use only)
$
$
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.
52. Your signature
53. Spouse's signature (if joint return filed)
54. Date
State Tax Department Use Only Below This Line
Financial Verification / Analysis
Item
Date Information or
Encumbrance
Verified
Date Property
Inspected
Estimate
Forced Sale
Equity
Real Estate
Vehicles
Other Personal Property
Income Tax Return
Sources of Income / Credit Bureau
Other Assets / Liabilities
Additional information or comments:
0.00
0.00
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Form 433A: West Virginia State Tax Department (State of West Virginia)

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Completed 13 August 2020

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