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

Collection Information Statement for Wage Earners and Self-Employed Individuals
Form 433-A (OIC) (Rev. 4-2023)
Form

433-A (OIC)
(April 2023)

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 who is personally responsible for a partnership
liability (only if the partnership is submitting an offer)
● An individual who is submitting an offer on behalf of the
estate of a deceased person

● 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.

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

Married

Own your home

If married, date of marriage (mm/dd/yyyy)

-

Do you
Rent

Other (specify e.g., share rent, live with relative, etc.)

If you were married and lived in AZ, CA, ID, LA, NM, NV, TX, WA or WI within the last ten years check here
County of residence

Primary phone
(

Secondary phone
(

)

)

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

Pay period

Weekly

Bi-weekly

Monthly

Other

Employer’s address (street, city, state, ZIP code)

Do you have an ownership interest in this business
Yes (also complete and submit Form 433-B)

No

Your occupation

How long with this employer

Spouse’s employer's name

Pay period

(years)

(months)
Weekly

Bi-weekly

Monthly

Other

Employer’s address (street, city, state, ZIP code)

Does your spouse have an ownership interest in this business
Yes (also complete and submit Form 433-B)
Spouse's occupation

No
How long with this employer
(years)

Catalog Number 55896Q

(months)

www.irs.gov

Form 433-A

(OIC) (Rev. 4-2023)

Page 2

Section 3

Personal Asset Information (Domestic and Foreign)

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, retirement accounts (IRAs, Keogh, 401(k) plans, stocks, bonds, mutual funds, certificates of deposit) and
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.), life insurance policies that have a cash value, and safe deposit boxes including those located in foreign
countries or jurisdictions. 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). Ensure you also include assets located in foreign countries or jurisdictions and add
attachment(s) if additional space is needed to respond.
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 and country location

Online Account

Stored Value Card

Account number
(1a) $

Checking

Savings

Money Market Account/CD

Bank name and country location

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 and country location

Account number

Current market value

Minus loan balance

$

X .8 = $

Investment account

Stocks

– $
Bonds

=

(2a) $

Other

Name of Financial Institution and country location

Account number

Current market value

Minus loan balance

$

X .8 = $

– $

Name of digital asset such as virtual
currency wallet, exchange or digital
currency exchange (DCE)

Digital asset
Type of digital asset

Name of individual who has access to the private
key(s) and/or digital wallets

=

Email address used to set-up the digital
asset such as virtual currency exchange
or DCE

(2b) $
Location(s) of digital asset (mobile
wallet, online, and/or external
hardware storage)

Digital asset amount and value in US dollars as of today
$

=

(2c) $

Total investment accounts from attachment. [current market value minus loan balance(s)]

(2d) $

Add lines (2a) through (2d) =

(2) $

Retirement account

401K

IRA

Other

Name of Financial Institution and country location

Account number

Current market value
$

Minus loan balance
X .8 = $

– $

=

(3a) $

Total of retirement accounts from attachment. [current market value X .8 minus loan balance(s)]

(3b) $

Add lines (3a) through (3b) =

(3) $

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. 4-2023)

Page 3

Section 3 (Continued)

Personal Asset Information (Domestic and Foreign)

Real property (enter information about any house, condo, co-op, time share, etc. that you own or are buying including any assets owned by
your spouse if you live in a community property state)
Is your real property currently for sale or do you anticipate selling your real property to fund the offer amount
Yes

No

(listing price)

Property description (indicate if personal residence, rental property, vacant, etc.)

Purchase date (mm/dd/yyyy)

Amount of mortgage payment

How title is held (joint tenancy, etc.)

Date of final payment

Location (street, city, state, ZIP code, county, and country)

Lender/Contract holder name, address (street, city,
state, ZIP code) and phone

Minus loan balance (mortgages, etc.)

Current market value
$

X .8 = $

– $

(total value of real estate) =

Property description (indicate if personal residence, rental property, vacant, etc.)

Purchase date (mm/dd/yyyy)

Amount of mortgage payment

How title is held (joint tenancy, etc.)

Date of final payment

Location (street, city, state, ZIP code, county, and country)

(5a) $

Lender/Contract holder name, address (street, city,
state, ZIP code) and phone

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).
Include those located in foreign countries or jurisdictions. If additional space is needed, list on an attachment.
Vehicle make & model

Lease

Year

Date purchased

Name of creditor

Mileage

Date of final payment

Monthly lease/loan amount

Own

$

Current market value
$

Minus loan balance
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

Date purchased

Name of creditor

Mileage

Date of final payment

License/Tag number

Monthly lease/loan amount

Own

$

Current market value
$

License/Tag number

Minus loan balance
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. 4-2023)

Page 4

Section 3 (Continued)

Personal Asset Information (Domestic and Foreign)

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(s)
Current market value

Minus loan balance

$

X .8 = $

– $

=

(7a) $

=

(7b) $

Total value of valuable items listed from attachment [current market value X .8 minus any loan balance(s)]

(7c) $

Value of remaining furniture and personal effects (not listed above)
Description of asset
Minus loan balance

Current market value
$

X .8 = $

– $

Add lines (7a) through (7c) minus IRS deduction of $10,810 =
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 =

(7) $
Box A
Available Individual Equity in Assets
$

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 address

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

Section 5

Corporation

Other

Business Asset Information (for Self-Employed) (Domestic and Foreign)

List business assets such as bank accounts, digital assets (cryptocurrency), 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 and country location

Online Account

Stored Value Card

Account number
(8a) $

Cash

Checking

Savings

Money Market Account/CD

Bank name and country location

Online Account

Stored Value Card

Account number
(8b) $

Digital asset
Type of digital asset

Name of digital asset such as virtual
currency wallet, exchange or digital
currency exchange (DCE)

Name of individual who has access to the private
key(s) and/or digital wallets

Email address used to set-up the digital
asset such as virtual currency exchange
or DCE

Digital asset amount and value in US dollars as of today
$

Catalog Number 55896Q

Location(s) of digital asset (mobile
wallet, online, and/or external
hardware storage)

=

(8c) $

Total bank accounts from attachment

(8d) $

Add lines (8a) through (8d) =

(8) $

www.irs.gov

Form 433-A

(OIC) (Rev. 4-2023)

Page 5

Section 5 (Continued)

Business Asset Information (for Self-Employed) (Domestic and Foreign)

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 for individuals and sole-proprietors –

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, provide a list of your current accounts receivable (include the age and amount)
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.
Period provided beginning

through
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. 4-2023)

Page 6

Section 7

Monthly Household Income and Expense Information

Enter your household's average gross monthly income. Gross monthly income includes wages, social security, pension, unemployment, and other
income. Examples of other income include but are not limited to: agricultural subsidies, gambling income, oil credits, rent subsidies, sharing economy
income from providing on-demand work, services or goods (e.g., Uber, Lyft, AirBnB, VRBO), income through digital platforms like an app or website,
etc., and recurring capital gains from the sale of securities including cryptocurrency, non-fungible tokens, etc. 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 = (31) $
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. List source(s)
(32) $
Interest, dividends, and royalties

(33) $

Distributions (e.g., income from partnerships, sub-S Corporations, etc.)

(34) $

Net rental income

(35) $

Net business income from Box C [Deductions for non-cash expenses on Schedule C (e.g., depreciation, depletion, etc.) are
not permitted as an expense for offer purposes and must be added back in to the net income figure]

(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.

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. For the other boxes input your actual expenses. 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,
monthly rent payment
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
Public transportation costs (e.g., average monthly cost of fares for mass transit such as bus, train, ferry, etc.). A reasonable
estimate of these expenses may be used
Health insurance premiums

(42) $
(43) $
(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) $

Life insurance policy amount

Current monthly taxes (e.g., monthly cost of federal, state, and local tax, personal property tax, etc.)

(49) $

Secured debts/Other (e.g., any loan where you pledged an asset as collateral not previously listed, government guaranteed
student loan, employer required retirement or dues) List debt(s)/expense(s)

(50) $

Enter the amount of your monthly delinquent state and/or local tax payment(s) . Total tax owed

(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 = $
Catalog Number 55896Q

www.irs.gov

Form 433-A

(OIC) (Rev. 4-2023)

Page 7

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 (which included the amount(s) allowed for vehicles and bank
accounts) do not apply if the 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.

=

$

$

Place the offer amount shown above on the Form 656, Section 4, Payment Terms, unless you cannot pay that amount due to
special circumstances. If you cannot pay that amount due to special circumstances, place the amount you can pay on the
Form 656, Section 4, Payment Terms, and explain your special circumstances on the Form 656, Offer in Compromise, Section
3, Reason for Offer.

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 a party to or involved in litigation (if yes, answer the following)
Plaintiff

Yes

Location of filing

Represented by

Possible completion date (mmddyyyy)

Subject of litigation

No

Docket/Case number

Defendant
Amount of dispute
$
Have you filed bankruptcy in the past 7 years (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)

Yes

No

Yes

No

Location filed

To (mmddyyyy)

Are you or have you ever been party to any litigation involving the IRS/United States (including any tax litigation)

Yes

No

If yes and the litigation included tax debt, provide the types of tax and periods involved

Yes

Are you the beneficiary of a trust, estate, or life insurance policy, including those located in foreign countries or jurisdictions

No

(if yes, answer the following)

Place where recorded
Name of the trust, estate, or policy

EIN
Anticipated amount to be received

When will the amount be received

$
Are you a trustee, fiduciary, or contributor of a trust
Name of the trust

Yes

No

Yes

No

EIN

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))

Value

Contents

$

Catalog Number 55896Q

www.irs.gov

Form 433-A

(OIC) (Rev. 4-2023)

Page 8

Section 9 (Continued)

Other Information

In the past 10 years, have you transferred any asset with a fair market value of more than $10,000 including real property, for
less than their full value (if yes, answer the following)
Value at time of transfer

List asset(s)

Date transferred (mmddyyyy)

Yes

No

To whom or where was it transferred

$
Do you have any assets or own any real property outside the U.S.

Yes

No

Yes

No

If yes, provide description, location, and value

Do you have any funds being held in trust by a third party
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, royalties, agricultural subsidies, gambling income, oil credits, rent subsidies, sharing economy income from
providing on-demand work, services or goods (e.g., Uber, Lyft, AirBnB, VRBO), income through digital platforms like an app or
website, etc., and recurring capital gains from the sale of securities including cryptocurrency, non-fungible tokens.
Copies of individual complete bank statements for the three most recent months. If you operate a business, copies of the six
most recent complete statements for each business bank account.
Completed Form 433-B (Collection Information Statement for Businesses) if you or your spouse have an interest in a business
entity other than a sole-proprietorship.
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 Accounts Receivable or Notes Receivable, if applicable.
Verification of delinquent State/Local Tax Liability showing total delinquent state/local taxes and amount of monthly payments, if
applicable.
Copies of court orders for child support/alimony payments claimed in monthly expense section.
Copies of Trust documents if applicable per Section 9.
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. Ensure all years and forms involved in your offer are listed on Form 2848 and include the
current tax year. Check the appropriate box to ensure copies of communications are sent to your representative.
Completed and signed current Form 656.

Catalog Number 55896Q

www.irs.gov

Form 433-A

(OIC) (Rev. 4-2023)