Federal Collection Information Statement for Wage Earners

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)