Fillable Collection Information Statement Jan-2017 Form-433-F

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Collection Information Statement Jan-2017 Form-433-F

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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.

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Catalog Number 62053J www.irs.gov
Form
433-F (Rev. 1-2017)
Form 433-F
(January 2017)
Department of the Treasury - Internal Revenue Service
Collection Information Statement
Name(s) and Address
If address provided above is different than last return filed,
please check here
County of Residence
Your Social Security Number or Individual Taxpayer Identification Number
Your Spouse’s Social Security Number or Individual Taxpayer Identification Number
Your Telephone Numbers
Home:
Work:
Cell:
Spouse’s Telephone Numbers
Home:
Work:
Cell:
Enter the number of people in the household who can be claimed on this year’s tax return including you and your spouse. Under 65 65 and Over
If you or your spouse are self employed or have self employment income, provide the following information:
Name of Business Business EIN
Type of Business
Number of Employees
(not counting owner)
A. ACCOUNTS / LINES OF CREDIT Include checking, online, mobile (e.g., PayPal) and savings accounts, Certificates of Deposit,
Trusts, Individual Retirement Accounts (IRAs), Keogh Plans, Simplified Employee Pensions, 401(k) Plans, Profit Sharing Plans, Mutual
Funds, Stocks, Bonds and other investments. If applicable, include business accounts. (Use additional sheets if necessary.)
Name and Address of Institution
Account Number
Type of
Account
Current
Balance/Value
Check if
Business Account
B. REAL ESTATE Include home, vacation property, timeshares, vacant land and other real estate. (Use additional sheets if necessary.)
Description/Location/County Monthly Payment(s) Financing Current Value Balance Owed Equity
Primary Residence Other
Year Purchased Purchase Price
Year Refinanced
Refinance Amount
Primary Residence Other
Year Purchased Purchase Price
Year Refinanced Refinance Amount
C. OTHER ASSETS Include cars, boats, recreational vehicles, whole life policies, etc. Include make, model and year of vehicles
and name of Life Insurance company in Description. If applicable, include business assets such as tools, equipment, inventory, etc.
(Use additional sheets if necessary.)
Description Monthly Payment Year Purchased Final Payment (mo/yr) Current Value Balance Owed Equity
/
/
/
/
/
/
D. CREDIT CARDS (Visa, MasterCard, American Express, Department Stores, etc.)
Type Credit Limit Balance Owed Minimum Monthly Payment
TURN PAGE TO CONTINUE
Catalog Number 62053J www.irs.gov
Form
433-F (Rev. 1-2017)
Page 2 of 4
E. BUSINESS INFORMATION Complete E1 for Accounts Receivable owed to you or your business. (Use additional sheets if necessary.)
Complete E2 if you or your business accepts credit card payments.
E1. Accounts Receivable owed to you or your business
Name Address Amount Owed
List total amount owed from additional sheets
Total amount of accounts receivable available to pay to IRS now
E2. Name of individual or business on account
Credit Card
(Visa, Master Card, etc.)
Issuing Bank Name and Address Merchant Account Number
F. EMPLOYMENT INFORMATION If you have more than one employer, include the information on another sheet of paper.
(If attaching a copy of current pay stub, you do not need to complete this section.)
Your current Employer (name and address)
How often are you paid? (Check one)
Weekly Biweekly Semi-monthly Monthly
Gross per pay period
Taxes per pay period (Fed)
(State) (Local)
How long at current employer
Spouse’s current Employer (name and address)
How often are you paid? (Check one)
Weekly Biweekly Semi-monthly Monthly
Gross per pay period
Taxes per pay period (Fed)
(State) (Local)
How long at current employer
G. NON-WAGE HOUSEHOLD INCOME List monthly amounts. For Self-Employment and Rental Income, list the monthly amount
received after expenses or taxes and attach a copy of your current year profit and loss statement.
Alimony Income
Child Support Income
Net Self Employment Income
Net Rental Income
Unemployment Income
Pension Income
Interest/Dividends Income
Social Security Income
Other:
H. MONTHLY NECESSARY LIVING EXPENSES List monthly amounts. (For expenses paid other than monthly, see instructions.)
1. Food / Personal Care See instructions. If you do not spend more than
the standard allowable amount for your family size, fill in the Total amount
only.
Actual Monthly
Expenses
IRS Allowed
Food
Housekeeping Supplies
Clothing and Clothing Services
Personal Care Products & Services
Miscellaneous
Total
2. Transportation
Actual Monthly
Expenses
IRS Allowed
Gas / Insurance / Licenses /
Parking / Maintenance etc.
Public Transportation
Total
3. Housing & Utilities
Actual Monthly
Expenses
IRS Allowed
Rent
Electric, Oil/Gas, Water/Trash
Telephone/Cell/Cable/Internet
Real Estate Taxes and Insurance
(if not included in B above)
Maintenance and Repairs
Total
4. Medical
Actual Monthly
Expenses
IRS Allowed
Health Insurance
Out of Pocket Health Care
Expenses
Total
5. Other
Actual Monthly
Expenses
IRS Allowed
Child / Dependent Care
Estimated Tax Payments
Term Life Insurance
Retirement (Employer Required)
Retirement (Voluntary)
Union Dues
Delinquent State & Local Taxes
(minimum payment)
Student Loans (minimum
payment)
Court Ordered Child Support
Court Ordered Alimony
Other Court Ordered Payments
Other (specify)
Other (specify)
Other (specify)
Total
Under penalty of perjury, I declare 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
National Standards
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signature
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dd mmm yyyy
Catalog Number 62053J www.irs.gov
Form
433-F (Rev. 1-2017)
Page 3 of 4
Instructions for Form 433-F, Collection Information Statement
What is the purpose of Form 433F?
Form 433-F is used to obtain current financial information
necessary for determining how a wage earner or self-employed
individual can satisfy an outstanding tax liability.
Note: You may be able to establish an Online Payment
Agreement on the IRS web site. To apply online, go to
https://www.irs.gov, click on “I need to pay my taxes,” and select
“Installment Agreement” under the heading “What if I can't pay
now?”
If you are requesting an Installment Agreement, you should
submit Form 9465, Installment Agreement Request, along with
Form 433-F. (A large down payment may streamline the
installment agreement process, pay your balance faster and
reduce the amount of penalties and interest.
Please retain a copy of your completed form and supporting
documentation. After we review your completed form, we may
contact you for additional information. For example, we may ask
you to send supporting documentation of your current income or
substantiation of your stated expenditures.
If any section on this form is too small for the information
you need to supply, please use a separate sheet.
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. Include
business accounts, if applicable. If you are entering information
for a stock or bond, etc. and a question does not apply, enter N/A.
Section B – Real Estate
List all real estate you own or are purchasing including your
home. Include insurance and taxes if they are included in your
monthly payment. The county/description is needed if different
than the address and county you listed above. To determine
equity, subtract the amount owed for each piece of real estate
from its current market value.
Section C – Other Assets
List all cars, boats and recreational vehicles with their make,
model and year. If a vehicle is leased, write “lease” in the “year
purchased” column. List whole life insurance policies with the
name of the insurance company. List other assets with a
description such as “paintings”, “coin collection”, or “antiques”. If
applicable, include business assets, such as tools, equipment,
inventory, and intangible assets such as domain names, patents,
copyrights, etc. To determine equity, subtract the amount owed
from its current market value. If you are entering information for
an asset and a question does not apply, enter N/A.
List all credit cards and lines of credit, even if there is no balance
owed.
Section D – Credit Cards
Section E – Business Information
Complete this section if you or your spouse are self-employed, or
have self-employment income. This includes self-employment
income from online sales.
E1: List all Accounts Receivable owed to you or your business.
Include federal, state and local grants and contracts.
E2: Complete if you or your business accepts credit card
payments (e.g., Visa, MasterCard, etc.).
Section F – Employment Information
Complete this section if you or your spouse are wage earners.
If attaching a copy of current pay stub, you do not need to
complete this section.
Section G – Non-Wage Household Income
List all non-wage income received monthly.
Net Self-Employment Income is the amount you or your
spouse earns 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. Please attach a copy of Schedule C or
your current year profit and loss statement. 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. Depreciation is a non-cash
expense. Only cash expenses are used to determine ability to
pay).
If net rental income is a loss, enter “0”.
Other Income includes 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. It also includes agricultural subsidies, gambling income, oil
credits, and rent subsidies. Enter total distributions from IRAs if
not included under Pension Income.
Section H – Monthly Necessary Living
Expenses
Enter monthly amounts for expenses. For any expenses not paid
monthly, convert as follows:
If a bill is paid …
Calculate the monthly
amount by …
Quarterly Dividing by 3
Weekly Multiplying by 4.3
Biweekly (every two
weeks)
Multiplying by 2.17
Semimonthly (twice
each month)
Multiplying by 2
Catalog Number 62053J www.irs.gov
Form
433-F (Rev. 1-2017)
Page 4 of 4
For expenses claimed in boxes 1 and 4, you should provide the
IRS allowable standards, or the actual amount you pay if the
amount exceeds the IRS allowable standards. IRS allowable
standards can be found by accessing https://www.irs.gov/
businesses/small-businesses-self-employed/collection-financial-
standards.
Substantiation may be required for any expenses over the
standard once the financial analysis is completed.
The amount claimed for Miscellaneous cannot exceed the
standard amount for the number of people in your family. 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.
If you do not have access to the IRS web site, itemize your actual
expenses and we will ask you for additional proof, if required.
Documentation may include pay statements, bank and investment
statements, loan statements and bills for recurring expenses, etc.
Housing and Utilities – Includes expenses for your primary
residence. You should only list amounts for utilities, taxes and
insurance that are not included in your mortgage or rent
payments.
Rent – Do not enter mortgage payment here. Mortgage
payment is listed in Section B.
Transportation – Include the total of maintenance, repairs,
insurance, fuel, registrations, licenses, inspections, parking, and
tolls for one month.
Public Transportation – Include the total you spend for
public transportation if you do not own a vehicle or if you have
public transportation costs in addition to vehicle expenses.
Medical – You are allowed expenses for health insurance and
out-of-pocket health care costs.
Health insurance – Enter the monthly amount you pay for
yourself or your family.
Out-of-Pocket health care expenses – are costs not
covered by health insurance, and include:
• Medical services
• Prescription drugs
• Dental expenses
• Medical supplies, including eyeglasses and contact
lenses. Medical procedures of a purely cosmetic nature,
such as plastic surgery or elective dental work are
generally not allowed.
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.
Delinquent State & Local Taxes – Enter the minimum
amount you are required to pay monthly. Be prepared to provide
a copy of the statement showing the amount you owe and if
applicable, any agreement you have for monthly payments.
Student Loans – Minimum payments on student loans for
the taxpayer’s post-secondary education may be allowed if they
are guaranteed by the federal government. Be prepared to
provide proof of loan balance and payments.
Court Ordered Payments – For any court ordered
payments, be prepared to submit a copy of the court order portion
showing the amount you are ordered to pay, the signatures, and
proof you are making the payments. Acceptable forms of proof
are copies of cancelled checks or copies of bank or pay
statements.
Other Expenses not listed above – We may allow
other expenses in certain circumstances. For example, if the
expenses are necessary for the health and welfare of the
taxpayer or family, or for the production of income. Specify the
expense and list the minimum monthly payment you are billed.
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Collection Information Statement Jan-2017 Form-433-F

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Completed 18 May 2019

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