The IRS 433-A form is a financial disclosure document used by the Internal Revenue Service to evaluate an individual’s ability to pay tax debts. This form provides a comprehensive overview of one’s income, expenses, assets, and liabilities, helping the IRS determine appropriate payment options. If you need to fill out the form, please click the button below.
The IRS 433-A form plays a critical role for individuals facing tax liabilities and seeking to negotiate their financial obligations with the Internal Revenue Service. This form is primarily used to provide a comprehensive financial disclosure to the IRS, detailing income, expenses, assets, and liabilities. By accurately completing the 433-A, taxpayers can help the IRS assess their ability to pay and potentially qualify for various tax relief options, such as an installment agreement or an offer in compromise. It is essential to include all necessary information, as any discrepancies or omissions could lead to delays or rejections of requests. Understanding the nuances of the 433-A can empower taxpayers to take control of their financial situation and navigate the complexities of tax resolution more effectively. The form is not only a means of communication with the IRS but also a vital tool for individuals to demonstrate their financial standing and negotiate a manageable path forward.
Form 433-A
Collection Information Statement for Wage
(July 2022)
Earners and Self-Employed Individuals
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
1b
Address (street, city, state, ZIP code and country)
Name
Age
Relationship
3a
Do you or your spouse have any outside business interests? Include
any interest in an LLC, LLP, corporation, partnership, etc.
1c
County of Residence
1d
Home Phone
Yes (percentage of ownership
%)
No
(
)
Title
1e
Cell Phone
1f
Work Phone
3b
Business name
2a
Marital Status:
Married
Unmarried (Single, Divorced, Widowed)
3c
Type of business (select one)
2b
SSN or ITIN
Date of Birth (mmddyyyy)
Partnership
LLC
Corporation
Taxpayer
Other
Spouse
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.
4a
Taxpayer's Employer Name
5a
Spouse's Employer Name
4b
5b
4c
Work Telephone Number
4d
Does employer allow contact at work
5c
5d Does employer allow contact at work
Yes
4e
How long with this employer
4f
Occupation
5e
5f Occupation
(years)
(months)
4g
Number claimed as a dependent
4h
Pay Period:
5g
5h Pay Period:
on your Form 1040
Weekly
Bi-weekly
Monthly
Section 3: Other Financial Information (Attach copies of applicable documentation)
6
Are you a party to a lawsuit (If yes, answer the following)
Location of Filing
Represented by
Docket/Case No.
Plaintiff
Defendant
Amount of Suit
Possible Completion Date (mmddyyyy)
Subject of Suit
$
7
Have you ever filed bankruptcy (If yes, answer the following)
Date Filed (mmddyyyy)
Date Dismissed (mmddyyyy)
Date Discharged (mmddyyyy)
Petition No.
Location Filed
8
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)
Yes No
Place where recorded:
EIN:
Name of the trust, estate, or policy
Anticipated amount to be received
When will the amount be received
9b
Are you a trustee, fiduciary, or contributor of a trust
Name of the trust:
10
Do you have a safe deposit box (business or personal) including those located in foreign countries or jurisdictions
(If yes, answer the following)
Location (Name, address and box number(s))
Contents
Value
11
In the past 10 years, have you transferred any assets with a fair market value of more than $10,000 including real
property, for less than their full value (if yes, answer the following)
List Asset(s)
Value at Time of Transfer
Date Transferred (mmddyyyy)
To Whom or Where was it Transferred
Catalog Number 20312N
www.irs.gov
Form 433-A (Rev. 7-2022)
Page 2
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.).
Full Name & Address (Street, City, State, ZIP code and
Account Balance
Type of Account
Country) of Bank, Savings & Loan, Credit Union, or
Account Number
As of
Financial Institution
mmddyyyy
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
Full Name & Address
Loan Balance (if applicable)
Equity
Current Value
or Financial Interest
(Street, City, State, ZIP code and Country) of Company
Value minus Loan
14a
Phone
14b
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
Name of Digital Asset such as
Email Address Used to Set-up
Digital Asset Amount
Location(s) of Digital Assets
and Value in US
Type of Digital Asset
Virtual Currency Wallet, Exchange
With the Digital Assets such as
(Mobile Wallet, Online, and/or
dollars as of today
or Digital Currency Exchange
Virtual Currency Exchange or
External Hardware storage)
(e.g., 1 Bitcoins
(DCE)
DCE
$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.
Amount Owed
Available Credit
Credit Limit
(Street, City, State, ZIP code and Country) of Credit Institution
15a
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.
16b
Name and Address of Insurance
Company(ies):
16c
Policy Number(s)
16d
Owner of Policy
16e
Current Cash Value
16f
Outstanding Loan Balance
16g
Total Available Cash (Subtract amounts on line 16f from line 16e and include amounts from any attachments)
Page 3
Section 4: Personal Asset Information for all Individuals (Foreign and Domestic) (Continued)
REAL PROPERTY Include all real property owned or being purchased
Purchase Date
Current Fair
Current Loan
Amount of
Date of Final
Market Value
Payment
(mmddyyyy)
Balance
Monthly Payment
FMV Minus Loan
(FMV)
17a
Property Description
Location (street, city, state, ZIP code, county and country)
Lender/Contract Holder Name, Address (street, city, state, ZIP code), and Phone
17b
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,
Purchase/
Lease Date
Tag Number, Vehicle Identification Number)
18a Year
Make/Model
Mileage
License/Tag Number
Lender/Lessor Name, Address (street, city, state, ZIP code and country), and Phone
Vehicle Identification Number
18b Year
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.
19a Property Description
Lender/Lessor Name, Address (street, city, state, ZIP code), and Phone
19b Property Description
19c Total Equity (Add lines 19a, 19b and amounts from any attachments)
Page 4
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)
IRS USE ONLY
Source
Gross Monthly
Expense Items 6
Actual Monthly
Allowable Expenses
20
Wages (Taxpayer) 1
35
Food, Clothing and Misc. 7
21
Wages (Spouse) 1
36
Housing and Utilities 8
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)
1Wages, 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
2Net 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.
3Net 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.
4Distributions: 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.
5Other 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.
6Expenses 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.
7Food, 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.
8Housing 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.
9Vehicle Ownership Costs: Total of monthly lease or purchase/loan payments.
10Vehicle Operating Costs: Total of maintenance, repairs, insurance, fuel, registrations, licenses, inspections, parking, and tolls for one month.
11Public Transportation: Total of monthly fares for mass transit (e.g., bus, train, ferry, taxi, etc.)
12Out of Pocket Health Care Costs: Monthly total of medical services, prescription drugs and medical supplies (e.g., eyeglasses, hearing aids, etc.)
13Current 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)
Filling out the IRS 433-A form is an important step in providing the IRS with detailed financial information. This form is typically used for individuals who owe taxes and are seeking to establish a payment plan or settle their tax debt. Properly completing the form ensures that the IRS has a clear understanding of your financial situation, which can help in negotiating a resolution.
The IRS 433-A form is a financial disclosure form used by individuals who owe back taxes to the Internal Revenue Service (IRS). This form helps the IRS assess your financial situation, allowing them to determine the best way to collect any outstanding tax debts. By providing detailed information about your income, expenses, assets, and liabilities, you can work towards a resolution, such as an installment agreement or an offer in compromise.
If you owe taxes and are unable to pay the full amount, you may be required to fill out the IRS 433-A form. This includes individuals who are negotiating payment plans or offers in compromise. If your financial situation has changed significantly, such as a loss of income or unexpected expenses, completing this form can help the IRS understand your current ability to pay.
Completing the IRS 433-A form involves several steps:
Be honest and thorough; the IRS relies on this information to evaluate your financial situation.
You can find the IRS 433-A form on the official IRS website. It is available for download in PDF format. Just search for "IRS 433-A" in the forms section. Additionally, you may also be able to obtain a copy from a tax professional or a local IRS office.
After submitting the IRS 433-A form, the IRS will review your financial information. This review process can take some time, so patience is key. The IRS may reach out to you for additional information or clarification. Once they have assessed your situation, they will propose a payment plan or other options for resolving your tax debt.
Yes, if you disagree with the IRS's decision after submitting the IRS 433-A form, you have the right to appeal. The appeals process allows you to contest the IRS's findings or proposed resolutions. It’s advisable to consult with a tax professional to guide you through this process and help you present your case effectively.
No, there is no fee to submit the IRS 433-A form itself. However, if you choose to work with a tax professional to assist you in completing the form or negotiating with the IRS, there may be associated costs for their services. Always weigh the benefits against the costs when deciding to seek professional help.
The processing time for the IRS 433-A form can vary. Typically, it may take several weeks to a few months for the IRS to review your submission and respond. Factors such as the complexity of your financial situation and the current workload of the IRS can influence this timeline. Staying proactive and following up can help ensure your case is moving forward.
Inaccurate Personal Information: Many individuals fail to provide correct personal details such as name, Social Security number, and address. This can lead to delays in processing the form.
Incomplete Financial Information: Some people neglect to include all sources of income or fail to list assets accurately. This omission can affect the assessment of their financial situation.
Ignoring Expenses: Individuals often underestimate or overlook necessary living expenses. The IRS needs a clear picture of monthly expenses to determine payment options.
Failure to Sign the Form: A common mistake is submitting the form without a signature. This can result in the IRS rejecting the application or delaying the review process.
Not Keeping Copies: Many people forget to retain a copy of the completed form for their records. Having a copy is crucial for future reference or if questions arise.
The IRS 433-A form is a crucial document for individuals looking to negotiate their tax liabilities with the IRS. It provides a detailed overview of an individual's financial situation, including income, expenses, and assets. However, several other forms and documents may be required to support your case. Here’s a list of additional forms and documents that are often used alongside the IRS 433-A form.
Gathering these documents can streamline the process of negotiating with the IRS. Each piece of information contributes to a comprehensive view of your financial situation, helping to ensure that your case is presented clearly and effectively.
The IRS Form 433-A is similar to the IRS Form 433-B, which is used by businesses to report financial information. While Form 433-A focuses on individual taxpayers, Form 433-B is tailored for business entities. Both forms require detailed disclosures of assets, liabilities, income, and expenses. They serve the same purpose of providing the IRS with a clear picture of a taxpayer's financial situation, allowing for informed decisions regarding tax liabilities and payment plans.
Another document comparable to Form 433-A is the IRS Form 656, the Offer in Compromise. This form is used by taxpayers who wish to settle their tax debts for less than the total amount owed. Like Form 433-A, Form 656 requires financial disclosures to assess the taxpayer's ability to pay. Both forms work together in the negotiation process with the IRS, as the financial information provided helps determine eligibility for an offer in compromise.
The IRS Form 4506-T is also similar in that it allows taxpayers to request a transcript of their tax return information. While it does not require the same level of detailed financial disclosure as Form 433-A, it serves the purpose of providing the IRS with necessary information regarding a taxpayer's financial history. Both forms are essential tools in managing tax matters, as they facilitate communication and verification of financial data between the taxpayer and the IRS.
IRS Form 1040, the individual income tax return, shares similarities with Form 433-A as both documents require comprehensive financial information from taxpayers. Form 1040 includes details about income, deductions, and credits, while Form 433-A focuses on assets and liabilities. Both forms are critical in understanding a taxpayer's overall financial picture and play a role in tax compliance and planning.
Lastly, the IRS Form 8821, Tax Information Authorization, is relevant in this context. This form allows taxpayers to authorize a third party to receive and inspect their tax information. While it does not require financial details, it complements Form 433-A by enabling communication between the taxpayer and authorized representatives. Both forms are important for ensuring that financial information is handled correctly and that the IRS has the necessary data to assist in tax matters.
When filling out the IRS 433-A form, it's important to follow certain guidelines to ensure accuracy and compliance. Here are seven things you should and shouldn't do:
Following these guidelines will help ensure a smoother process with the IRS.
The IRS Form 433-A is often misunderstood. Here are four common misconceptions about this form, along with clarifications to help clear up any confusion.
This is not true. While the form is commonly used by those with significant tax debts, it can also be required for individuals seeking to negotiate payment plans or settle their tax liabilities, regardless of the amount owed.
Filling out the form does not automatically lead to a reduction. It is merely a tool that provides the IRS with your financial information, which they will review to determine eligibility for various relief options.
While the form may seem daunting, many individuals can complete it on their own. Clear instructions are provided, and with careful attention to detail, it can be filled out without professional help.
This is a common belief, but it is not accurate. While submitting the form may initiate a review process, it does not automatically halt collection actions. It is crucial to communicate with the IRS about your situation to explore options.
The IRS 433-A form is an important document used for reporting financial information to the IRS. Here are some key takeaways to keep in mind when filling out and using this form:
By following these guidelines, you can navigate the process of filling out the IRS 433-A form more effectively, ensuring that your financial situation is communicated clearly to the IRS.