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Federal Free Printable Form 433-A (OIC) (Rev. 3-2018) for 2019 Federal Collection Information Statement for Wage Earners and Self-Employed Individuals

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Collection Information Statement for Wage Earners and Self-Employed Individuals
Form 433-A (OIC) (Rev. 3-2018)

Form 433-A (OIC) (March 2018) Department of the Treasury — Internal Revenue Service Collection Information Statement for Wage Earners and Self-Employed Individuals Use this form if you are ► An individual who owes income tax on a Form 1040, U.S. Individual Income Tax Return ► An individual with a personal liability for Excise Tax ► An individual responsible for a Trust Fund Recovery Penalty ► An individual who is self-employed or has self-employment income. You are considered to be self-employed if you are in business for yourself, or carry on a trade or business. ► An individual who is personally responsible for a partnership liability (only if the partnership is submitting an offer) ► An individual who operated as a disregarded single member Limited Liability Company (LLC) taxed as a sole proprietor prior to 2009 ► An individual who is submitting an offer on behalf of the estate of a deceased person Note: Include attachments if additional space is needed to respond completely to any question. This form should only be used with the Form 656, Offer in Compromise. Section 1 Personal and Household Information Last Name First Name Social Security Number Date of Birth (mm/dd/yyyy) Marital status Home Physical Address (Street, City, State, ZIP Code) Unmarried Own your home Rent Other (specify e.g., share rent, live with relative, etc.) Married County of Residence Primary Phone ( Secondary Phone ( - Do you: ) ) Home Mailing Address (if different from above or Post Office Box number) - Fax Number - ( ) - Provide information about your spouse. Spouse's Last Name Spouse's First Name Date of Birth (mm/dd/yyyy) Social Security Number - - Provide information for all other persons in the household or claimed as a dependent. Name Section 2 Age Relationship Claimed as a dependent on your Form 1040? Contributes to household income? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Employment Information for Wage Earners Complete this section if you or your spouse are wage earners and receive a Form W-2. If you or your spouse have self-employment income (that is you file a Schedule C, E, F, etc.) instead of, or in addition to wage income, you must also complete Business Information in Sections 4, 5, and 6. Your Employer’s Name Do you have an ownership interest in this business? Yes No Your Occupation Employer’s Address (street, city, state, zip code) If yes, check the business interest that applies: Partner Officer Sole proprietor How long with this employer (years) (months) Spouse’s Employer's Name Does your spouse have an ownership interest in this business? Yes No Spouse's Occupation Employer’s Address (street, city, state, zip code) If yes, check the business interest that applies: Partner Officer Sole proprietor How long with this employer (years) Catalog Number 55896Q www.irs.gov (months) Form 433-A (OIC) (Rev. 3-2018) Page 2 of 8 Section 3 Personal Asset Information Use the most current statement for each type of account, such as checking, savings, money market and online accounts, stored value cards (such as, a payroll card from an employer), investment and retirement accounts (IRAs, Keogh, 401(k) plans, stocks, bonds, mutual funds, certificates of deposit, and virtual currency such as Bitcoin, Ripple and Litecoin), life insurance policies that have a cash value, and safe deposit boxes. Asset value is subject to adjustment by IRS based on individual circumstances. Enter the total amount available for each of the following (if additional space is needed include attachments). Round to the nearest dollar. Do not enter a negative number. If any line item is a negative number, enter "0". Cash and Investments (domestic and foreign) Cash Checking Savings Money Market Account/CD Bank Name Online Account Stored Value Card Virtual Currency Account Number (1a) $ Checking Savings Money Market Account/CD Bank Name Online Account Stored Value Card Account Number (1b) $ Investment Account: Stocks Bonds Total of bank accounts from attachment (1c) $ Add lines (1a) through (1c) minus ($1,000) = (1) $ Other Name of Financial Institution Account Number Current Market Value Minus Loan Balance $ X .8 = $ – $ = (2a) $ = (2b) $ Total investment accounts from attachment. [current market value X.8 minus loan balance(s)] (2c) $ Add lines (2a) through (2c) = (2) $ Investment Account: Stocks Bonds Other Name of Financial Institution Account Number Current Market Value Minus Loan Balance $ X .8 = $ Retirement Account: 401K IRA – $ Other Name of Financial Institution Account Number Current Market Value Minus Loan Balance $ X .8 = $ – $ = (3a) $ = (3b) $ Total of retirement accounts from attachment. [current market value X .8 minus loan balance(s)] (3c) $ Add lines (3a) through (3c) = (3) $ Retirement Account: 401K IRA Other Name of Financial Institution Account Number Current Market Value $ Minus Loan Balance X .8 = $ – $ Note: Your reduction from current market value may be greater than 20% due to potential tax consequences/withdrawal penalties. Cash Value of Life Insurance Policies Name of Insurance Company Current Cash Value $ Total cash value of life insurance policies from attachment $ Catalog Number 55896Q Policy Number Minus Loan Balance – $ = (4a) $ = (4b) $ Add lines (4a) through (4b) = (4) $ Minus Loan Balance(s) – $ www.irs.gov Form 433-A (OIC) (Rev. 3-2018) Page 3 of 8 Section 3 (Continued) Personal Asset Information Real Estate (Enter information about any house, condo, co-op, time share, etc. that you own or are buying) Property Address (Street Address, City, State, ZIP Code) Primary Residence Yes No Date Purchased County and Country Date of Final Payment How title is held (joint tenancy, etc.) Description of Property Minus Loan Balance (Mortgages, etc.) Current Market Value $ X .8 = $ – $ Property Address (Street Address, City, State, ZIP Code) (Total Value of Real Estate) = Primary Residence Yes (5a) $ No Date Purchased County and Country Date of Final Payment How title is held (joint tenancy, etc.) Description of Property Minus Loan Balance (Mortgages, etc.) Current Market Value $ X .8 = $ – $ (Total Value of Real Estate) = (5b) $ Total value of property(s) from attachment [current market value X .8 minus any loan balance(s)] (5c) $ Add lines (5a) through (5c) = (5) $ Vehicles (Enter information about any cars, boats, motorcycles, etc. that you own or lease) Vehicle Make & Model Lease Year Name of Creditor Date Purchased Mileage Date of Final Payment Monthly Lease/Loan Amount Loan $ Current Market Value $ Minus Loan Balance (Mortgages, etc.) X .8 = $ Vehicle Make & Model Lease Total value of vehicle (if the vehicle is leased, enter 0 as the total value) = (6a) $ Subtract $3,450 from line (6a) (If line (6a) minus $3,450 is a negative number, enter "0") (6b) $ – $ Year Name of Creditor Date Purchased Mileage Date of Final Payment Monthly Lease/Loan Amount Loan $ Current Market Value $ Minus Loan Balance (Mortgages, etc.) Total value of vehicle (if the vehicle is leased, enter 0 as the total value) = (6c) $ If you are filing a joint offer, subtract $3,450 from line (6c) (If line (6c) minus $3,450 is a negative number, enter "0") If you are not filing a joint offer, enter the amount from line (6c) (6d) $ Total value of vehicles listed from attachment [current market value X .8 minus any loan balance(s)] (6e) $ X .8 = $ – $ Total lines (6b), (6d), and (6e) = Catalog Number 55896Q www.irs.gov (6) $ Form 433-A (OIC) (Rev. 3-2018) Page 4 of 8 Section 3 (Continued) Personal Asset Information Other valuable items (artwork, collections, jewelry, items of value in safe deposit boxes, interest in a company or business that is not publicly traded, etc.) Description of asset: Current Market Value Minus Loan Balance $ X .8 = $ – $ = (7a) $ = (7b) $ Description of asset: Current Market Value Minus Loan Balance $ X .8 = $ – $ Value of remaining furniture and personal effects (not listed above) Description of asset: Minus Loan Balance Current Market Value $ X .8 = $ – $ = (7c) $ Total value of valuable items listed from attachment [current market value X .8 minus any loan balance(s)] (7d) $ Add lines (7a) through (7d) = (7) $ Box A Available Individual Equity in Assets Do not include amount on the lines with a letter beside the number. Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative, enter "0" on that line. Add lines (1) through (7) and enter the amount in Box A = $ NOTE: If you or your spouse are self-employed, Sections 4, 5, and 6 must be completed before continuing with Sections 7 and 8. Section 4 Self-Employed Information If you or your spouse are self-employed (e.g., files Schedule(s) C, E, F, etc.), complete this section. Is your business a sole proprietorship? Yes Address of Business (If other than personal residence) No Name of Business Business Telephone Number ( ) Employer Identification Number Business Website Total Number of Employees Frequency of Tax Deposits - Description of Business Do you or your spouse have any other business interests? Include any interest in an LLC, LLP, corporation, partnership, etc. Yes Trade Name or DBA (Percentage of ownership: Average Gross Monthly Payroll $ Business Address (Street, City, State, ZIP code) ) Title: No Business Name Employer Identification Number Business Telephone Number ( ) - Type of business (Select one) Partnership LLC Corporation Section 5 Other Business Asset Information (for Self-Employed) List business assets such as bank accounts, tools, books, machinery, equipment, business vehicles and real property that is owned/leased/rented. If additional space is needed, attach a list of items. Do not include personal assets listed in Section 3. Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative number, enter "0". Cash Checking Savings Money Market Account/CD Bank Name Online Account Stored Value Card Account Number (8a) $ Cash Checking Savings Money Market Account/CD Bank Name Online Account Stored Value Card Account Number (8b) $ Catalog Number 55896Q www.irs.gov Total bank accounts from attachment (8c) $ Add lines (8a) through (8c) = (8) $ Form 433-A (OIC) (Rev. 3-2018) Page 5 of 8 Section 5 (Continued) Business Asset Information (for Self-Employed) Description of asset: Total Value (if leased or used in the production of income, enter 0 as the total value) = (9a) $ Total Value (if leased or used in the production of income, enter 0 as the total value) = (9b) $ Total value of assets listed from attachment [current market value X .8 minus any loan balance(s)] (9c) $ Current Market Value $ Minus Loan Balance X .8 = $ – $ Description of asset: Current Market Value $ Minus Loan Balance X .8 = $ – $ Add lines (9a) through (9c) = IRS allowed deduction for professional books and tools of trade – Enter the value of line (9) minus line (10). If less than zero enter zero. = (9) $ (10) $ (11) $ Notes Receivable Do you have notes receivable? Yes No If yes, attach current listing that includes name(s) and amount of note(s) receivable. Accounts Receivable Do you have accounts receivable, including e-payment, factoring companies, and any bartering or online auction accounts? Yes No If yes, you may be asked to provide a list of your account(s) receivable. Do not include amounts from the lines with a letter beside the number [for example: (9c)]. Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative, enter "0" on that line. Box B Available Business Equity in Assets Add lines (8) and (11) and enter the amount in Box B = $ Section 6 Business Income and Expense Information (for Self-Employed) If you provide a current profit and loss (P&L) statement for the information below, enter the total gross monthly income on line 17 and your monthly expenses on line 29 below. Do not complete lines (12) - (16) and (18) - (28). You may use the amounts claimed for income and expenses on your most recent Schedule C; however, if the amount has changed significantly within the past year, a current P&L should be submitted to substantiate the claim. Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative number, enter "0". Business Income (You may average 6-12 months income/receipts to determine your Gross monthly income/receipts.) Gross receipts (12) $ Gross rental income (13) $ Interest income (14) $ Dividends (15) $ Other income (16) $ Add lines (12) through (16) = (17) $ Business Expenses (You may average 6-12 months expenses to determine your average expenses.) Materials purchased (e.g., items directly related to the production of a product or service) (18) $ Inventory purchased (e.g., goods bought for resale) (19) $ Gross wages and salaries (20) $ Rent (21) $ Supplies (items used to conduct business and used up within one year, e.g., books, office supplies, professional equipment, etc.) (22) $ Utilities/telephones (23) $ Vehicle costs (gas, oil, repairs, maintenance) (24) $ Business Insurance (25) $ Current Business Taxes (e.g., Real estate, excise, franchise, occupational, personal property, sales and employer's portion of employment taxes) (26) $ Secured debts (not credit cards) (27) $ Other business expenses (include a list) (28) $ Add lines (18) through (28) = (29) $ Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative, enter "0" on that line. Box C Net Business Income Subtract line (29) from line (17) and enter the amount in Box C = $ Catalog Number 55896Q www.irs.gov Form 433-A (OIC) (Rev. 3-2018) Page 6 of 8 Section 7 Monthly Household Income and Expense Information Enter your household's gross monthly income. The information below is for yourself, your spouse, and anyone else who contributes to your household's income. The entire household includes spouse, non-liable spouse, significant other, children, and others who contribute to the household. This is necessary for the IRS to accurately evaluate your offer. Monthly Household Income Note: Entire household income should also include income that is considered not taxable and may not be included on your tax return. Round to the nearest whole dollar. Primary taxpayer Gross Wages $ Social Security Pension(s) + $ + $ + Other Income (e.g. unemployment) Total primary $ taxpayer income = (30) $ Spouse Gross Wages Social Security Pension(s) Other Income (e.g. unemployment) Total spouse $ + $ + $ + $ income = Additional sources of income used to support the household, e.g., non-liable spouse, or anyone else who may contribute to the household income, etc. (31) $ Interest and dividends (33) $ Distributions (e.g., income from partnerships, sub-S Corporations, etc.) (34) $ Net rental income (35) $ Net business income from Box C (36) $ Child support received (37) $ Alimony received (38) $ Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative, enter "0" on that line. (32) $ Box D Total Household Income Add lines (30) through (38) and enter the amount in Box D = $ Monthly Household Expenses Enter your average monthly expenses. Note: For expenses claimed in boxes (39) and (45) only, you should list the full amount of the allowable standard even if the actual amount you pay is less. You may find the allowable standards at http://www.irs.gov/Businesses/Small-Businesses-&Self-Employed/Collection-Financial-Standards. Round to the nearest whole dollar. Food, clothing, and miscellaneous (e.g., housekeeping supplies, personal care products , minimum payment on credit card). A reasonable estimate of these expenses may be used. (39) $ Housing and utilities (e.g., rent or mortgage payment and average monthly cost of property taxes, home insurance, maintenance, dues, fees and utilities including electricity, gas, other fuels, trash collection, water, cable television and internet, telephone, and cell phone). (40) $ Vehicle loan and/or lease payment(s) (41) $ Vehicle operating costs (e.g., average monthly cost of maintenance, repairs, insurance, fuel, registrations, licenses, inspections, parking, tolls, etc.). A reasonable estimate of these expenses may be used. (42) $ Public transportation costs (e.g., average monthly cost of fares for mass transit such as bus, train, ferry, taxi, etc.). A reasonable estimate of these expenses may be used. (43) $ Health insurance premiums (44) $ Out-of-pocket health care costs (e.g. average monthly cost of prescription drugs, medical services, and medical supplies like eyeglasses, hearing aids, etc.) (45) $ Court-ordered payments (e.g., monthly cost of any alimony, child support, etc.) (46) $ Child/dependent care payments (e.g., daycare, etc.) (47) $ Life insurance premiums (48) $ Current monthly taxes (e.g., monthly cost of federal, state, and local tax, personal property tax, etc.) (49) $ Catalog Number 55896Q www.irs.gov Form 433-A (OIC) (Rev. 3-2018) Page 7 of 8 Section 7 Monthly Household Income and Expense Information (Continued) Secured debts (e.g., any loan where you pledged an asset as collateral not previously listed, government guaranteed Student Loan) (50) $ Enter the amount of your monthly delinquent State and/or Local Tax payment(s) (51) $ Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative, enter "0" on that line. Box E Total Household Expenses Add lines (39) through (51) and enter the amount in Box E = $ Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative, enter "0" on that line. Box F Remaining Monthly Income Subtract Box E from Box D and enter the amount in Box F = $ Section 8 Calculate Your Minimum Offer Amount The next steps calculate your minimum offer amount. The amount of time you take to pay your offer in full will affect your minimum offer amount. Paying over a shorter period of time will result in a smaller minimum offer amount. Note: The multipliers below (12 and 24) and the calculated offer amount do not apply if IRS determines you have the ability to pay your tax debt in full within the legal period to collect. Round to the nearest whole dollar. If you will pay your offer in 5 or fewer payments within 5 months or less, multiply "Remaining Monthly Income" (Box F) by 12 to get "Future Remaining Income" (Box G). Do not enter a number less than $0. Enter the total from Box F Box G Future Remaining Income $ X 12 = $ If you will pay your offer in 6 to 24 months, multiply "Remaining Monthly Income" (Box F) by 24 to get "Future Remaining Income" (Box H). Do not enter a number less than $0. Enter the total from Box F Box H Future Remaining Income $ X 24 = $ Determine your minimum offer amount by adding the total available assets from Box A and Box B (if applicable) to the amount in either Box G or Box H. Enter the amount from Box A plus Box B (if applicable) $ Enter the amount from either Box G or Box H + $ Offer Amount Your offer must be more than zero ($0). Do not leave blank. Use whole dollars only. = $ If you cannot pay the Offer Amount shown above due to special circumstances, explain on the Form 656, Offer in Compromise, Section 3, Reason for Offer, Explanation of Circumstances. You must offer an amount more than $0. Section 9 Other Information Additional information IRS needs to consider settlement of your tax debt. If you or your business are currently in a bankruptcy proceeding, you are not eligible to apply for an offer. Are you the beneficiary of a trust, estate, or life insurance policy? Yes No Are you currently in bankruptcy? Yes No Discharge/Dismissal Date (mm/dd/yyyy) Have you filed bankruptcy in the past 10 years? Yes No Location Filed Are you or have you been party to a lawsuit? Yes No If yes, date the lawsuit was resolved: (mm/dd/yyyy) Are you or have you been party to any lawsuits involving the IRS/United States (including any suits regarding tax matters)? Yes No If yes and the suit included tax debt, provide the types of tax and periods involved. Catalog Number 55896Q www.irs.gov Form 433-A (OIC) (Rev. 3-2018) Page 8 of 8 In the past 10 years, have you transferred any assets for less than their full value? Yes No If yes, provide date, value, and type of asset transferred: (mm/dd/yyyy) In the past 3 years have you transferred any real property (land, house, etc.)? Yes No If yes, list the type of property, value, and date of the transfer. Have you lived outside the U.S. for 6 months or longer in the past 10 years? Yes No Do you have any assets or own any real property outside the U.S.? Yes No If yes, provide description, location, and value. Do you have any funds being held in trust by a third party? Yes No If yes, how much $ Section 10 Where: Signatures Under penalties of perjury, I declare that I have examined this offer, including accompanying documents, and to the best of my knowledge it is true, correct, and complete. ► ► Signature of Taxpayer Date (mm/dd/yyyy) Signature of Spouse Date (mm/dd/yyyy) Remember to include all applicable attachments listed below. Copies of the most recent pay stub, earnings statement, etc., from each employer Copies of the most recent statement for each investment and retirement account Copies of the most recent statement, etc., from all other sources of income such as pensions, Social Security, rental income, interest and dividends (including any received from a related partnership, corporation, LLC, LLP, etc.), court order for child support, alimony, and rent subsidies Copies of individual bank statements for the three most recent months. If you operate a business, copies of the six most recent statements for each business bank account. Copies of the most recent statement from lender(s) on loans such as mortgages, second mortgages, vehicles, etc., showing monthly payments, loan payoffs, and balances List of Notes Receivable, if applicable Verification of delinquent State/Local Tax Liability, if applicable Documentation to support any special circumstances described in the “Explanation of Circumstances” on Form 656, if applicable Attach a Form 2848, Power of Attorney, if you would like your attorney, CPA, or enrolled agent to represent you and you do not have a current form on file with the IRS. Completed and signed Form 656 Catalog Number 55896Q www.irs.gov Form 433-A (OIC) (Rev. 3-2018)
Extracted from PDF file 2018-federal-form-433-a-oic.pdf, last modified March 2018

More about the Federal Form 433-A (OIC) Other TY 2018

We last updated the Collection Information Statement for Wage Earners and Self-Employed Individuals in December 2018, so this is the latest version of Form 433-A (OIC), fully updated for tax year 2018. You can download or print current or past-year PDFs of Form 433-A (OIC) 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 (OIC).

Form Code Form Name
Form 433-A Collection Information Statement for Wage Earners

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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 (OIC) from the Internal Revenue Service in December 2018.

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Historical Past-Year Versions of Federal Form 433-A (OIC)

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


2018 Form 433-A (OIC)

Form 433-A (OIC) (Rev. 3-2018)

2017 Form 433-A (OIC)

Form 433-A; Collection Information Statement for Wage Earners and Self-Employed Individuals (Rev. January 2014) Catalog Number 55896Q

2016 Form 433-A (OIC)

Form 433-A; Collection Information Statement for Wage Earners and Self-Employed Individuals (Rev. January 2014) Catalog Number 55896Q

Collection Information Statement for Wage Earners and Self-Employed Individuals 2015 Form 433-A (OIC)

Form 433-A; Collection Information Statement for Wage Earners and Self-Employed Individuals (Rev. January 2014) Catalog Number 55896Q

Collection Information Statement for Wages Earners and Self-Employed Individuals 2012 Form 433-A (OIC)

Form 433-A (OIC) (Rev. May 2012)


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