• Collection Information Statement for Wage Earners and Self-Employed Individuals

  • 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 6. 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 including the signature line on page 6. 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.

  • Section 1: Personal Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • 2a Marital Status:
  • Rows
  • 2c Provide information for all other persons in the household or claimed as a dependent.
    Rows
  • 3a Do you or your spouse have any outside business interests? Include any interest in an LLC, LLP, corporation, partnership, etc.
  • 3c Type of business (select one)

  • 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.
  • 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.
    Rows
  • Format: (000) 000-0000.
  • 4d Does employer allow contact at work
  • Format: (000) 000-0000.
  • 5d Does employer allow contact at work
  • 4h Pay Period:
  • 5h Pay Period:

  • Section 3: Other Financial Information (Attach copies of applicable documentation)

  • 6 Any increase/decrease in income anticipated (If yes, answer the following)
  • 7 Are you a party to a lawsuit (If yes, answer the following)
  • Role in Lawsuit
  • Possible Completion Date (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year
  • 8 Have you ever filed bankruptcy (If yes, answer the following)
  • Date Filed (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date Dismissed (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date Discharged (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year

  • Section 3: Other Financial Information (Attach copies of applicable documentation) (Continued)

  • 8a Do you have a United States passport
  • 8b In the past 10 years, have you lived outside of the U.S for 6 months or longer (If yes, answer the following)
  • Dates lived abroad: From (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year
  • To (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year
  • 8c Do you have dual citizenship (If yes, answer the following)
  • 9a Are you currently incarcerated (If yes, provide your inmate number)
  • 9b Are you the beneficiary of a trust, estate, or life insurance policy including those located in foreign countries or jurisdictions (If yes, answer the following)
  • 9c Are you a trustee, fiduciary, or contributor of a trust
  • 10 Do you have a safe deposit box (business or personal) including those located in foreign countries or jurisdictions (If yes, answer the following)
  • 11 In the past 10 years, have you transferred any assets with a fair market value of more than $10,000 including real property, for less than their full value (if yes, answer the following)
  • Date Transferred (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year

  • Section 4: Personal Asset Information for all Individuals (Foreign and Domestic). Include assets located in foreign countries or jurisdictions and add attachment(s) if additional space is needed to respond

  • PERSONAL BANK ACCOUNTS Include all checking, online and mobile (e.g., PayPal etc.) accounts, money market accounts, savings accounts, and stored value cards (e.g., payroll cards, government benefit cards, etc.).
    Rows
  • 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.
    Rows

  • Section 4: Personal Asset Information for all Individuals (Foreign and Domestic) (Continued)

  • DIGITAL ASSETS List all digital assets such as virtual currency (cryptocurrency), non-fungible token (NFT), and smart contracts 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.
  • 15 List the name(s) of individuals who have access to the private key(s) and/or digital wallets
    Rows
  • AVAILABLE CREDIT Include all lines of credit and bank issued credit cards.
    Rows
  • 17 LIFE INSURANCE Do you own or have any interest in any life insurance policies with cash value

  • Section 4: Personal Asset Information for all Individuals (Foreign and Domestic) (Continued)

  • Section 4: Personal Asset Information for all Individuals (Foreign and Domestic) (Continued)
    Rows
  • PERSONAL VEHICLES LEASED AND PURCHASED Include boats, RVs, motorcycles, all-terrain and off-road vehicles, trailers, etc.
    Rows

  • 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.

  • 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.
    Rows
  • 20a Purchase/ Lease Date (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year
  • 20a Date of Final Payment (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • 20b Purchase/ Lease Date (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year
  • 20b Date of Final Payment (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Form 433-A (Rev. 6-2026)

  • If you are self-employed, sections 6 and 7 must be completed before continuing.

  • Section 5: Monthly Income and Expenses (Foreign and Domestic)

  • Rows
  • 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 8, line 90. 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, sharing economy income from providing on-demand work, services or goods (e.g., Uber, Lyft, AirBnb, VRBO) and income through digital platforms like an app or website (e.g., YouTube, TikTok), etc. Recurring capital gains from the sale of securities including cryptocurrency and non-fungible tokens.
    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.
  • Clear
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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)
  • Monthly Income/Expense Statement (For additional information, refer to Publication 1854.)
  • Section 5: Monthly Income and Expenses (Foreign and Domestic)
    Rows
  • Clear

  • Section 6: Business Information (Foreign and Domestic)

  • 52 Is the business a sole proprietorship (filing Schedule C)
  • Format: (000) 000-0000.
  • 56 Is the business a Federal Contractor
  • 61 Does the business engage in e-Commerce (Internet sales)? If yes, complete lines 62a and 62b
  • PAYMENT PROCESSOR (e.g., PayPal, Authorize.net, Google Checkout, BitPay, Crypto.com, etc.) Include virtual currency wallet, exchange or digital currency exchange.
    Rows
  • CREDIT CARDS ACCEPTED BY THE BUSINESS
    Rows
  • 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.
    Rows
  • 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.
    Rows

  • 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.

  • 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.
    Rows
  • Format: (000) 000-0000.
  • 67b Purchase/Lease Date (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year
  • 67b Date of Final Payment (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Section 7 should be completed only if you are SELF-EMPLOYED

  • Section 7: Sole Proprietorship Information (lines 68 through 88 should reconcile with business Profit and Loss Statement)

  • Accounting Method Used:
  • Use the prior 3, 6, 9 or 12 month period to determine your typical business income and expenses.
  • to (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Provide a breakdown below of your average monthly income and expenses, based on the period of time used above.
  • Total Monthly Business Expenses (Amounts reported in U.S. dollars) (Use attachments as needed)
    Rows
  • Enter the monthly net income amount from line 90 on line 24, section 5. If line 90 is a loss, enter "0" on line 24, section 5.
    Self-employed taxpayers must return to page 6 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 6). 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.
  • Income and Expenses during the period (mmddyyyy)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Total Monthly Business Income (Amounts reported in U.S. dollars)
    Rows
  •  
  • Should be Empty:
Select theme: