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Federal Free Printable Form 433-A (Rev. 7-2022) for 2024 Federal Collection Information Statement for Wage Earners

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Collection Information Statement for Wage Earners
Form 433-A (Rev. 7-2022)

Form 433-A Collection Information Statement for Wage Earners and Self-Employed Individuals (July 2022) Department of the Treasury Internal Revenue Service 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. Section 1: Personal Information 1a Full Name of Taxpayer and Spouse (if applicable) 2c Provide information on all other persons in household or claimed as dependents Name 1b Address (street, city, state, ZIP code and country) 1c County of Residence 1d Home Phone ( ) 1e Cell Phone ( ) 1f Work Phone ( ) 2a Marital Status: 2b Taxpayer Spouse Age Relationship 3a Do you or your spouse have any outside business interests? Include any interest in an LLC, LLP, corporation, partnership, etc. Yes (percentage of ownership Title 3b Business name Married Unmarried (Single, Divorced, Widowed) SSN or ITIN Date of Birth (mmddyyyy) %) 3c Type of business (select one) Partnership LLC Other No Corporation 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 Spouse 4a Taxpayer's Employer Name 5a Spouse's Employer Name 4b Address (street, city, state, ZIP code and country) 5b Address (street, city, state, ZIP code and country) 4c Work Telephone Number ( ) 5c Work Telephone Number ( ) 4d Does employer allow contact at work Yes No 4e How long with this employer 4f Occupation (years) (months) 4g Number claimed as a dependent 4h Pay Period: on your Form 1040 Weekly Bi-weekly Monthly Other 5d Does employer allow contact at work Yes No 5e How long with this employer 5f Occupation (years) (months) 5g Number claimed as a dependent 5h Pay Period: on your Form 1040 Weekly Bi-weekly Monthly Other Section 3: Other Financial Information (Attach copies of applicable documentation) 6 7 Are you a party to a lawsuit (If yes, answer the following) Location of Filing Represented by Plaintiff Defendant Amount of Suit Possible Completion Date (mmddyyyy) Subject of Suit $ Have you ever filed bankruptcy (If yes, answer the following) Date Filed (mmddyyyy) Date Dismissed (mmddyyyy) Date Discharged (mmddyyyy) Petition No. 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) To (mmddyyyy) 9a 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) Anticipated amount to be received $ 11 Contents 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) List Asset(s) Catalog Number 20312N Value at Time of Transfer $ Date Transferred (mmddyyyy) www.irs.gov Yes No Yes No Yes No EIN: When will the amount be received 9b Are you a trustee, fiduciary, or contributor of a trust Name of the trust: EIN: 10 Do you have a safe deposit box (business or personal) including those located in foreign countries or jurisdictions (If yes, answer the following) Location (Name, address and box number(s)) No Location Filed 8 Place where recorded: Name of the trust, estate, or policy Yes Docket/Case No. Yes No Yes No Value $ Yes No To Whom or Where was it Transferred Form 433-A (Rev. 7-2022) Page 2 Form 433-A (Rev. 7-2022) 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 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 etc.) accounts, money market accounts, savings accounts, and stored value cards (e.g., payroll cards, government benefit cards, etc.). Type of Account Full Name & Address (Street, City, State, ZIP code and Country) of Bank, Savings & Loan, Credit Union, or Financial Institution Account Balance As of mmddyyyy Account Number 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. Type of Investment or Financial Interest Full Name & Address (Street, City, State, ZIP code and Country) of Company Current Value Loan Balance (if applicable) As of mmddyyyy Equity Value minus Loan 14a Phone $ $ $ 14b Phone $ $ $ 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. 14c List the name(s) of individuals who have access to the private key(s) and/or digital wallets Type of Digital Asset Name of Digital Asset such as Email Address Used to Set-up Virtual Currency Wallet, Exchange With the Digital Assets such as or Digital Currency Exchange Virtual Currency Exchange or (DCE) DCE Location(s) of Digital Assets (Mobile Wallet, Online, and/or External Hardware storage) Digital Asset Amount and Value in US dollars as of today (e.g., 1 Bitcoins $38,000.00 USD) 14d $ 14e $ 14f Total Equity (Add lines 14a, 14b, 14d and 14e. Also include any amounts from any attachments to your total equity) $ AVAILABLE CREDIT Include all lines of credit and bank issued credit cards. Full Name & Address (Street, City, State, ZIP code and Country) of Credit Institution Credit Limit Amount Owed Available Credit As of As of mmddyyyy mmddyyyy 15a Acct. No $ $ $ Acct. No $ $ $ 15b 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 If yes, complete blocks 16b through 16f for each policy. Yes No $ 16b Name and Address of Insurance Company(ies): 16c 16d 16e 16f Policy Number(s) Owner of Policy Current Cash Value Outstanding Loan Balance $ $ $ $ 16g Total Available Cash (Subtract amounts on line 16f from line 16e and include amounts from any attachments) Catalog Number 20312N www.irs.gov $ $ $ Form 433-A (Rev. 7-2022) Page 3 Form 433-A (Rev. 7-2022) Section 4: Personal Asset Information for all Individuals (Foreign and Domestic) (Continued) REAL PROPERTY Include all real property owned or being purchased Current Fair Market Value (FMV) Purchase Date (mmddyyyy) 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, county and country) $ $ $ Lender/Contract Holder Name, Address (street, city, state, ZIP code), and Phone Phone 17b Property Description $ Location (street, city, state, ZIP code, county and country) $ $ $ 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 Mileage Purchase/ Lease Date (mmddyyyy) Current Fair Market Value (FMV) Current Loan Balance Date of Final Amount of Payment Monthly Payment (mmddyyyy) Equity FMV Minus Loan Make/Model License/Tag Number $ $ $ $ Lender/Lessor Name, Address (street, city, state, ZIP code and country), and Phone Vehicle Identification Number Phone 18b Year Mileage Make/Model License/Tag Number $ $ $ $ Lender/Lessor Name, Address (street, city, state, ZIP code and country), and Phone Vehicle Identification Number Phone 18c Total Equity (Add lines 18a, 18b 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. Purchase/ Lease Date (mmddyyyy) Current Fair Market Value (FMV) Current Loan Balance Date of Final Amount of Payment Monthly Payment (mmddyyyy) Equity FMV Minus Loan 19a Property Description $ Location (street, city, state, ZIP code, county and country) $ $ $ Lender/Lessor Name, Address (street, city, state, ZIP code), and Phone Phone 19b Property Description $ Location (street, city, state, ZIP code, county and country) $ $ $ Lender/Lessor Name, Address (street, city, state, ZIP code), and Phone Phone 19c Total Equity (Add lines 19a, 19b and amounts from any attachments) Catalog Number 20312N www.irs.gov $ Form 433-A (Rev. 7-2022) Page 4 Form 433-A (Rev. 7-2022) If you are self-employed, sections 6 and 7 must be completed before continuing. Section 5: Monthly Income and Expenses (Foreign and Domestic) Monthly Income/Expense Statement (For additional information, refer to Publication 1854.) Total Income (Amounts reported in U.S. dollars) Total Living Expenses (Amounts reported in U.S. dollars) Expense Items 6 Gross Monthly Source Actual Monthly 1 20 Wages (Taxpayer) $ 35 Food, Clothing and Misc. 7 $ $ 36 Housing and Utilities 8 $ 21 Wages (Spouse) 1 22 Interest - Dividends $ 37 Vehicle Ownership Costs 9 $ 23 Net Business Income 2 $ 38 Vehicle Operating Costs 10 $ 24 Net Rental Income 3 $ 39 Public Transportation 11 $ 25 Distributions (K-1, IRA, etc.) 4 $ 40 Health Insurance $ 26 Pension (Taxpayer) $ 41 Out of Pocket Health Care Costs 12 $ 27 Pension (Spouse) $ 42 Court Ordered Payments $ 28 Social Security (Taxpayer) $ 43 Child/Dependent Care $ 29 Social Security (Spouse) $ 44 Life Insurance $ 30 Child Support $ 45 Current year taxes (Income/FICA) 13 $ 31 Alimony $ 46 Secured Debts (Attach list) $ Other Income (Specify below) 5 47 Delinquent State or Local Taxes $ 32 $ 48 Other Expenses (Attach list) $ 33 $ 49 Total Living Expenses (add lines 35-48) $ 34 Total Income (add lines 20-33) $ 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, 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 10 11 12 13 Vehicle Ownership Costs: Total of monthly lease or purchase/loan payments. Vehicle Operating Costs: Total of maintenance, repairs, insurance, fuel, registrations, licenses, inspections, parking, and tolls for one month. Public Transportation: Total of monthly fares for mass transit (e.g., bus, train, ferry, taxi, etc.) Out of Pocket Health Care Costs: Monthly total of medical services, prescription drugs and medical supplies (e.g., eyeglasses, hearing aids, etc.) 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. 7-2022) Page 5 Form 433-A (Rev. 7-2022) Sections 6 and 7 must be completed only if you are SELF-EMPLOYED. Section 6: Business Information (Foreign and Domestic) 56 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) 52b Business Telephone Number ( ) Employer Identification Number 54 Type of Business 55 Is the business a Federal Contractor Yes No 57 Total Number of Employees 58 Average Gross Monthly Payroll Business Website (web address) 59 Frequency of Tax Deposits 51 52a 53 60 Does the business engage in e-Commerce (Internet sales) If yes, complete lines 61a and 61b Yes No PAYMENT PROCESSOR (e.g., PayPal, Authorize.net, Google Checkout, BitPay, Crypto.com, etc.) Include virtual currency wallet, exchange or digital currency exchange. Payment Processor Account Number Name & Address (Street, City, State, ZIP code, and Country) 61a 61b CREDIT CARDS ACCEPTED BY THE BUSINESS Credit Card Merchant Account Number Issuing Bank Name & Address (Street, City, State, ZIP code, and Country) 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 Account Balance Full name & Address (Street, City, State, ZIP code, and Country) of Bank, Savings & Loan, Credit Union or Financial Institution. Account Number 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, and Country) 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) Catalog Number 20312N www.irs.gov $ Form 433-A (Rev. 7-2022) Page 6 Form 433-A (Rev. 7-2022) 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) 66a Current Fair Market Value (FMV) Current Loan Balance Date of Final Amount of Payment Monthly Payment (mmddyyyy) Equity FMV Minus Loan Property Description $ $ $ $ Lender/Lessor/Landlord Name, Address (street, city, state, ZIP code), and Phone Location (street, city, state, ZIP code, and country) Phone 66b Property Description $ $ $ $ Lender/Lessor/Landlord Name, Address (street, city, state, ZIP code), and Phone Location (street, city, state, ZIP code, and country) Phone 66c Total Equity (Add lines 66a, 66b and amounts from any attachments) $ Section 7 should be completed only if you are SELF-EMPLOYED Section 7: Sole Proprietorship Information (lines 67 through 87 should reconcile with business Profit and Loss Statement) Accounting Method Used: Cash Accrual Use the prior 3, 6, 9 or 12 month period to determine your typical business income and expenses. Income and Expenses during the period (mmddyyyy) to (mmddyyyy) Provide a breakdown below of your average monthly income and expenses, based on the period of time used above. Total Monthly Business Income Total Monthly Business Expenses (Amounts reported in U.S. dollars) (Amounts reported in U.S. dollars) (Use attachments as needed) Expense Items Actual Monthly Source Gross Monthly Materials Purchased 1 $ Inventory Purchased 2 $ Gross Wages & Salaries $ Rent $ Supplies 3 $ Utilities/Telephone 4 $ $ Vehicle Gasoline/Oil $ 72 $ Repairs & Maintenance $ 73 $ Insurance $ 74 $ Current Taxes 5 $ 75 Other Expenses, including installment payments 76 Total Income (Add lines 67 through 75) $ (Specify) $ 88 Total Expenses (Add lines 77 through 87) $ 6 89 Net Business Income (Line 76 minus 88) $ 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 5 Current Taxes: Real estate, excise, franchise, occupational, production of a product or service. personal property, sales and employer’s portion of employment taxes. 2 Inventory Purchased: Goods bought for resale. 3 Supplies: Supplies are items used in the business that are 6 Net Business Income: Net profit from Form 1040, Schedule C may consumed or used up within one year. This could be the cost of be used if duplicated deductions are eliminated (e.g., expenses for books, office supplies, professional equipment, etc. business use of home already included in housing and utility expenses on page 4). Deductions for depreciation and depletion on 4 Utilities/Telephone: Utilities include gas, electricity, water, oil, other Schedule C are not cash expenses and must be added back to the fuels, trash collection, telephone, cell phone and business internet. net income figure. In addition, interest cannot be deducted if it is already included in any other installment payments allowed. 67 68 69 70 71 Gross Receipts Gross Rental Income Interest Dividends Cash Receipts not included in lines 67-70 Other Income (Specify below) $ $ $ $ $ 77 78 79 80 81 82 83 84 85 86 87 IRS USE ONLY (Notes) 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. Catalog Number 20312N www.irs.gov Form 433-A (Rev. 7-2022)
Extracted from PDF file 2023-federal-form-433-a.pdf, last modified July 2022

More about the Federal Form 433-A Other TY 2023

We last updated the Collection Information Statement for Wage Earners in February 2024, so this is the latest version of Form 433-A, fully updated for tax year 2023. You can download or print current or past-year PDFs of Form 433-A directly from TaxFormFinder. You can print other Federal tax forms here.


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Related Federal Other Forms:

TaxFormFinder has an additional 774 Federal income tax forms that you may need, plus all federal income tax forms. These related forms may also be needed with the Federal Form 433-A.

Form Code Form Name
Form 433-A (OIC) Collection Information Statement for Wage Earners and Self-Employed Individuals

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Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 433-A from the Internal Revenue Service in February 2024.

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Historical Past-Year Versions of Federal Form 433-A

We have a total of eleven past-year versions of Form 433-A in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2023 Form 433-A

Form 433-A (Rev. 7-2022)

2022 Form 433-A

Form 433-A (Rev. 7-2022)

2021 Form 433-A

Form 433-A (Rev. 5-2020)

2020 Form 433-A

Form 433-A (Rev. 5-2020)

2019 Form 433-A

Form 433-A (Rev. 2-2019)

2018 Form 433-A

Form 433-A (Rev. December 2012)

2017 Form 433-A

Form 433-A (Rev. December 2012)

2016 Form 433-A

Form 433-A (Rev. December 2012)

Collection Information Statement for Wage 2015 Form 433-A

Form 433-A (Rev. December 2012)

Collection Information Statement for Wage 2012 Form 433-A

Form 433-A (Rev. December 2012)

Collection Information Statement for Wage Earners and Self-Employed Individuals 2011 Form 433-A

Form 433-A (Rev. January 2008)


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