Fillable IRS - Form 433-A Collection Information Statement for Wage Earners and Self-Employed Individuals

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IRS - Form 433-A Collection Information Statement for Wage Earners and Self-Employed Individuals

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Catalog Number 20312N www.irs.gov
Form
433-A (Rev. 2-2019)
Form 433-A
(February 2019)
Department of the Treasury
Internal Revenue Service
Collection Information Statement for Wage
Earners and Self-Employed Individuals
Wage Earners Complete Sections 1, 2, 3, 4, and 5 including the signature line on page 4. Answer all questions or write N/A if the question is not applicable.
Self-Employed Individuals Complete Sections 1, 3, 4, 5, 6 and 7 and the signature line on page 4. Answer all questions or write N/A if the question is not applicable.
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
SSN or ITIN 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
( )
2a Marital Status: Married
Unmarried (Single, Divorced, Widowed)
2b Name, Age, and Relationship of dependent(s)
SSN or ITIN Date of Birth (mmddyyyy) Driver's License Number and State
3a Taxpayer
3b Spouse
Section 2: Employment Information for Wage Earners
If you or your spouse have self-employment income instead of, or in addition to wage income, complete Business Information in Sections 6 and 7.
Taxpayer
4a Taxpayer's Employer Name
4b Address (Street, City, State, and ZIP code)
4c
Work Telephone Number
( )
4d
Does employer allow contact at work
Yes No
4e
How long with this employer
(years) (months)
4f Occupation
4g
Number of withholding allowances
claimed on Form W-4
4h Pay Period:
Weekly
Monthly
Bi-weekly
Other
Spouse
5a
Spouse's Employer Name
5b Address (Street, City, State, and ZIP code)
5c
Work Telephone Number
( )
5d
Does employer allow contact at work
Yes No
5e
How long with this employer
(years) (months)
5f Occupation
5g
Number of withholding allowances
claimed on Form W-4
5h Pay Period:
Weekly
Monthly
Bi-weekly
Other
Section 3: Other Financial Information (Attach copies of applicable documentation)
6 Are you a party to a lawsuit (If yes, answer the following) Yes No
Plaintiff Defendant
Location of Filing Represented by Docket/Case No.
Amount of Suit
$
Possible Completion Date (mmddyyyy)
Subject of Suit
7 Have you ever filed bankruptcy (If yes, answer the following) Yes No
Date Filed (mmddyyyy)
Date Dismissed (mmddyyyy) Date Discharged (mmddyyyy)
Petition No. Location Filed
8 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)
9a 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
9b Are you a trustee, fiduciary, or contributor of a trust Yes No
Name of the trust: EIN:
10 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
$
11
In the past 10 years, have you transferred any assets for less than their full value (If yes, answer the following)
Yes No
List Asset(s)
Value at Time of Transfer
$
Date Transferred (mmddyyyy)
To Whom or Where was it Transferred
Catalog Number 20312N www.irs.gov
Form
433-A (Rev. 2-2019)
Form 433-A (Rev. 2-2019) Page 2
Section 4: Personal Asset Information for all Individuals (Foreign and Domestic)
12 CASH ON HAND Include cash that is not in a bank Total Cash on Hand
$
PERSONAL BANK ACCOUNTS Include all checking, online and mobile (e.g., PayPal) accounts, money market accounts, savings accounts, and
stored value cards (e.g., payroll cards, government benefit cards, etc.).
Total Available Cash (Subtract amounts on line 16f from line 16e and include amounts from any attachments)
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
13a $
13b $
13c Total Cash (Add lines 13a, 13b, and amounts from any attachments)
$
INVESTMENTS Include stocks, bonds, mutual funds, stock options, certificates of deposit, and retirement assets such as IRAs, Keogh, 401(k) plans
and commodities (e.g., gold, silver, copper, etc.). Include all corporations, partnerships, limited liability companies, or other business entities in which
you are an officer, director, owner, member, or otherwise have a financial interest. Include attachment(s) if additional space is needed to respond.
VIRTUAL CURRENCY (CRYPTOCURRENCY) List all virtual currency you own or in which you have a financial interest. (e.g., Bitcoin, Ethereum,
Litecoin, Ripple, etc.) If applicable, attach a statement with each virtual currency’s public key.
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
14a
Phone $ $ $
14b
Phone $ $ $
14e Total Equity (Add lines 14a through 14d and amounts from any attachments)
$
AVAILABLE CREDIT Include all lines of credit and bank issued credit cards.
Full Name & Address (Street, City, State, ZIP code) of Credit Institution
Credit Limit
Amount Owed
As of
mmddyyyy
Available Credit
As of
mmddyyyy
15a
Acct. No
$ $ $
15b
Acct. No $ $ $
15c Total Available Credit (Add lines 15a, 15b and amounts from any attachments) $
16a
LIFE INSURANCE Do you own or have any interest in any life insurance policies with cash value (Term Life insurance does not have a cash value)
Yes No
If yes, complete blocks 16b through 16f for each policy.
16b
Name and Address of Insurance
Company(ies):
16c Policy Number(s)
16d Owner of Policy
16e Current Cash Value $
16f Outstanding Loan Balance $
$
$
$
$
16g $
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
(Mobile Wallet, Online, and/or
External Hardware storage)
Virtual Currency
Amount and Value in
US dollars as of
today (e.g., 10 Bitcoins
$64,600.00 USD)
14c
$
14d
$
Catalog Number 20312N www.irs.gov
Form
433-A (Rev. 2-2019)
Form 433-A (Rev. 2-2019) Page 3
REAL PROPERTY Include all real property owned or being purchased
Purchase Date
(mmddyyyy)
Current Fair
Market Value
(FMV)
Current Loan
Balance
Amount of
Monthly Payment
Date of Final
Payment
(mmddyyyy)
Equity
FMV Minus Loan
17a Property Description
$ $ $ $
Location (Street, City, State, ZIP code) and County
Lender/Contract Holder Name, Address (Street, City, State, ZIP code), and Phone
Phone
17b Property Description
$ $ $ $
Location (Street, City, State, ZIP code) and County
Lender/Contract Holder Name, Address (Street, City, State, ZIP code), and Phone
Phone
17c Total Equity (Add lines 17a, 17b and amounts from any attachments) $
PERSONAL VEHICLES LEASED AND PURCHASED Include boats, RVs, motorcycles, all-terrain and off-road vehicles, trailers, etc.
Description (Year, Mileage, Make/Model,
Tag Number, Vehicle Identification Number)
18a Year Make/Model
Mileage License/Tag Number
Vehicle Identification Number
Purchase/
Lease Date
(mmddyyyy)
Current Fair
Market Value
(FMV)
$
Current Loan
Balance
$
Amount of
Monthly Payment
$
Date of Final
Payment
(mmddyyyy)
Equity
FMV Minus Loan
$
Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone
Phone
18b Year Make/Model
Mileage License/Tag Number
Vehicle Identification Number
$ $ $ $
Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone
Phone
18c Total Equity (Add lines 18a, 18b and amounts from any attachments) $
Purchase/
Lease Date
(mmddyyyy)
Current Fair
Market Value
(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
Phone
19b Property Description
$ $ $ $
Location (Street, City, State, ZIP code) and County Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone
Phone
19c Total Equity (Add lines 19a, 19b and amounts from any attachments)
$
PERSONAL ASSETS Include all furniture, personal effects, artwork, jewelry, collections (coins, guns, etc.), antiques or other assets. Include
intangible assets such as licenses, domain names, patents, copyrights, mining claims, etc.
Catalog Number 20312N www.irs.gov
Form
433-A (Rev. 2-2019)
Form 433-A (Rev. 2-2019) Page 4
If you are self-employed, sections 6 and 7 must be completed before continuing.
Section 5: Monthly Income and Expenses
Monthly Income/Expense Statement (For additional information, refer to Publication 1854.)
Total Income
Source
Gross Monthly
20 Wages (Taxpayer)
1
$
21 Wages (Spouse)
1
$
22 Interest - Dividends $
23 Net Business Income
2
$
24 Net Rental Income
3
$
25 Distributions (K-1, IRA, etc.)
4
$
26 Pension (Taxpayer) $
27 Pension (Spouse) $
28 Social Security (Taxpayer) $
29 Social Security (Spouse) $
30 Child Support $
31 Alimony $
Other Income (Specify below)
5
32 $
33 $
34 Total Income (add lines 20-33) $
Total Living Expenses
Expense Items
6
Actual Monthly
35 Food, Clothing and Misc.
7
$
36 Housing and Utilities
8
$
37 Vehicle Ownership Costs
9
$
38 Vehicle Operating Costs
10
$
39 Public Transportation
11
$
40 Health Insurance $
41 Out of Pocket Health Care Costs
12
$
42 Court Ordered Payments $
43 Child/Dependent Care $
44 Life Insurance $
45 Current year taxes (Income/FICA)
13
$
46 Secured Debts (Attach list) $
47 Delinquent State or Local Taxes $
48 Other Expenses (Attach list) $
49 Total Living Expenses (add lines 35-48)
$
50 Net difference (Line 34 minus 49) $
IRS USE ONLY
Allowable Expenses
1 Wages, salaries, pensions, and social security: Enter gross monthly wages and/or salaries. Do not deduct tax 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 89. 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 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.
4 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. Enter total distributions from IRAs if not included under pension income.
5 Other Income: Include agricultural subsidies, unemployment compensation, gambling income, oil credits, rent subsidies, etc.
6 Expenses not generally allowed: We generally do not allow tuition for private schools, public or private college expenses, charitable
contributions, voluntary retirement contributions or payments on unsecured debts. However, we may allow the expenses if proven that they are
necessary for the health and welfare of the individual or family or the production of income. See Publication 1854 for exceptions.
7 Food, Clothing and Miscellaneous: Total of food, clothing, housekeeping supplies, and personal care products for one month. The miscellaneous
allowance is for expenses incurred that are not included in any other allowable living expense items. Examples are credit card payments, bank fees
and charges, reading material, and school supplies.
8 Housing and Utilities: For principal residence: Total of rent or mortgage payment. Add the average monthly expenses for the following:
property taxes, homeowner’s or renter’s insurance, maintenance, dues, fees, and utilities. Utilities include gas, electricity, water, fuel, oil,
other fuels, trash collection, telephone, cell phone, cable television and internet services.
9
Vehicle Ownership Costs: Total of monthly lease or purchase/loan payments.
10
Vehicle Operating Costs: Total of maintenance, repairs, insurance, fuel, registrations, licenses, inspections, parking, and tolls for one month.
11
Public Transportation: Total of monthly fares for mass transit (e.g., bus, train, ferry, taxi, etc.)
12
Out of Pocket Health Care Costs: Monthly total of medical services, prescription drugs and medical supplies (e.g., eyeglasses, hearing aids, etc.)
13
Current Year Taxes: Include state and Federal taxes withheld from salary or wages, or paid as estimated taxes.
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.
Taxpayer's Signature Spouse's signature Date
After we review the completed Form 433-A, you may be asked to provide verification for the assets, encumbrances, income and expenses
reported. Documentation may include previously filed income tax returns, pay statements, self-employment records, bank and investment
statements, loan statements, bills or statements for recurring expenses, etc.
IRS USE ONLY (Notes)
Catalog Number 20312N www.irs.gov
Form
433-A (Rev. 2-2019)
Form 433-A (Rev. 2-2019) Page 5
Sections 6 and 7 must be completed only if you are SELF-EMPLOYED.
Section 6: Business Information
51
Is the business a sole proprietorship (filing Schedule C) Yes, Continue with Sections 6 and 7. No, Complete Form 433-B.
All other business entities, including limited liability companies, partnerships or corporations, must complete Form 433-B.
Business Name & Address (if different than 1b)52
53
Employer Identification Number
54
Type of Business Is the business a
Federal Contractor Yes No
56 Business Website (web address)
57
Total Number of Employees
58
Average Gross Monthly Payroll
59 Frequency of Tax Deposits 60 Does the business engage in e-Commerce
(Internet sales) If yes, complete lines 61a and 61b
Yes No
Name & Address (Street, City, State, ZIP code). Name & Address (Street, City, State, ZIP code)
Payment Processor Account Number
61a
61b
CREDIT CARDS ACCEPTED BY THE BUSINESS
Credit Card Merchant Account Number Issuing Bank Name & Address (Street, City, State, ZIP code)
62a
62b
62c
63 BUSINESS CASH ON HAND Include cash that is not in a bank. Total Cash on Hand $
BUSINESS BANK ACCOUNTS Include checking accounts, online and mobile (e.g., PayPal) 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
64a $
64b $
64c Total Cash in Banks (Add lines 64a, 64b 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, state and local government grants and contracts.
Accounts/Notes Receivable & Address (Street, City, State, ZIP code)
Status (e.g., age,
factored, other)
Date Due
(mmddyyyy)
Invoice Number or Government
Grant or Contract Number
Amount Due
65a $
65b $
65c $
65d $
65e $
65f Total Outstanding Balance (Add lines 65a through 65e and amounts from any attachments) $
55
PAYMENT PROCESSOR (e.g., PayPal, Authorize.net, Google Checkout, etc.) Include virtual currency wallet, exchange or digital currency exchange.
Catalog Number 20312N www.irs.gov
Form
433-A (Rev. 2-2019)
Form 433-A (Rev. 2-2019) Page 6
Section 7: Sole Proprietorship Information (lines 67 through 87 should reconcile with business Profit and Loss Statement)
BUSINESS ASSETS Include all tools, books, machinery, equipment, inventory or other assets used in trade or business. Include a list and show the
value of all intangible assets such as licenses, patents, domain names, copyrights, trademarks, mining claims, etc.
Purchase/
Lease Date
(mmddyyyy)
Current Fair
Market Value
(FMV)
Current Loan
Balance
Amount of
Monthly Payment
Date of Final
Payment
(mmddyyyy)
Equity
FMV Minus Loan
66a Property Description
$ $ $ $
Location (Street, City, State, ZIP code) and Country
Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code), and Phone
Phone
66b Property Description
$ $ $ $
Location (Street, City, State, ZIP code) and Country
Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code), and Phone
Phone
66c Total Equity (Add lines 66a, 66b and amounts from any attachments) $
Section 7 should be completed only if you are SELF-EMPLOYED
Accounting Method Used: Cash Accrual
Income and Expenses during the period (mmddyyyy) to (mmddyyyy)
Total Monthly Business Income
Source Gross Monthly
67 Gross Receipts $
68 Gross Rental Income $
69 Interest $
70 Dividends $
71 Cash Receipts not included in lines 67-70 $
Other Income (Specify below)
72
$
73
$
74
$
75
$
76 Total Income (Add lines 67 through 75) $
Total Monthly Business Expenses (Use attachments as needed)
Expense Items Actual Monthly
77 Materials Purchased
1
$
78 Inventory Purchased
2
$
79 Gross Wages & Salaries $
80 Rent $
81 Supplies
3
$
82 Utilities/Telephone
4
$
83 Vehicle Gasoline/Oil $
84 Repairs & Maintenance $
85 Insurance $
86 Current Taxes
5
$
87
Other Expenses, including installment payments
(Specify) $
88 Total Expenses (Add lines 77 through 87) $
89 Net Business Income (Line 76 minus 88)
6
$
Enter the monthly net income amount from line 89 on line 23, section 5. If line 89 is a loss, enter "0" on line 23, section 5.
Self-employed taxpayers must return to page 4 to sign the certification.
1 Materials Purchased: Materials are items directly related to the
production of a product or service.
2 Inventory Purchased: Goods bought for resale.
3 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.
4 Utilities/Telephone: Utilities include gas, electricity, water, oil, other
fuels, trash collection, telephone, cell phone and business internet.
5 Current Taxes: Real estate, excise, franchise, occupational,
personal property, sales and employer’s portion of employment
taxes.
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.
IRS USE ONLY (Notes)
Use the prior 3, 6, 9 or 12 month period to determine your typical business income and expenses.
Provide a breakdown below of your average monthly income and expenses, based on the period of time used above.
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.
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IRS - Form 433-A Collection Information Statement for Wage Earners and Self-Employed Individuals

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Completed 24 May 2020

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