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

In order to submit information to the IRS as a self-employed person, the following form has to be completed and submitted.

Extracted Text for Proper Search

Form 	433-A	
(Rev. December 2012)
Department of the Treasury 
Internal Revenue Service	
Collection Information Statement for Wage Earners and Self-Employed Individuals	
Wage Earners Complete Sections 1, 2, 3, 4, and 5 including the signature line on pag\
e 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 Sta\
tement."
Include attachments if additional space is needed to respond completely \
to any question.
Name on Internal Revenue Service (IRS) Account	
Social Security Number SSN on IRS Account	Employer Identification Number EIN	
Section 1: Personal Information
1a	Full Name of Taxpayer and Spouse (if applicable)	
1b	Address (Street, City, State, ZIP code) (County of Residence)	
1c	Home Phone
(	)	
1d Cell Phone	
(	)	
1e	Business Phone
(	)	
1f
Business Cell Phone	
(	)	
2a	Marital Status: 	Married	Unmarried (Single, Divorced, Widowed)	
2b	Name, Age, and Relationship of dependent(s)	
Social Security No. (SSN)	Date of Birth (mmddyyyy)	Driver's License Number and State	
3a	Taxpayer	
3b	Spouse	
Section 2: Employment Information for Wage Earners
If you or your spouse have self-employment income instead of, or in addi\
tion to wage income, complete Business Information in Sections 6 and 7.	
Taxpayer
4a	
Taxpayer's Employer Name	
4b	Address (Street, City, State, and ZIP code)	
4c Work Telephone Number	
(	)	
4d	Does employer allow contact at work	
Yes	No
4e	
How long with this employer	
(years) (months)	
4f	Occupation	
4g	Number of withholding allowances 
claimed on Form W-4	4h	Pay Period:
Weekly
Monthly	
Bi-weekly
Other	
Spouse
5a	
Spouse's Employer Name	
5b	Address (Street, City, State, and ZIP code)	
5c Work Telephone Number	
(	)	
5d	Does employer allow contact at work	
Yes	No	
5e	How long with this employer	
(years) (months)	
5f	Occupation
5g	
Number of withholding allowances 
claimed on Form W-4	5h Pay Period:	
Weekly
Monthly	
Bi-weekly
Other	
Section 3: Other Financial Information (Attach copies of applicable documentation)
6	Are you a party to a lawsuit (If yes, answer the following)	Yes	No	
Plaintiff	Defendant	
Location of Filing	Represented by	Docket/Case No.	
Amount of Suit
$	Possible Completion Date (mmddyyyy)	Subject of Suit	
7	Have you ever filed bankruptcy (If yes, answer the following)	Yes	No
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)	Yes	No
Dates lived abroad: from (mmddyyyy)	
To (mmddyyyy)	
9a	Are you the beneficiary of a trust, estate, or life insurance policy  (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	Yes	No
Name of the trust:	
EIN:	
10	Do you have a safe deposit box (business or personal) (If yes, answer the following)	Yes	No
Location (Name, address and box number(s))	
Contents	Value
$	
www.irs.gov	Cat. No. 20312N	Form 	433-A	 (Rev.12-2012)	
11	In the past 10 years, have you transferred any assets for less than thei\
r full value  (If yes, answer the following)	Yes	No
List Asset(s)	
Value at Time of Transfer
$	
Date Transferred (mmddyyyy)	To Whom or Where was it Transferred

Form 433-A (Rev. 12-2012)            Page  	2	
Section 4: Personal Asset Information for All Individuals
12CASH 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) accounts, money market accounts, savings accounts, and 
stored value cards (e.g., payroll cards, government benefit cards, etc.).	
Total Available Cash (Subtract amounts on line 16f from line 16e and include amounts from an\
y attachments)	
Form 	433-A	 (Rev. 12-2012)	
Type of Account	Full Name & Address (Street, City, State, ZIP code) of Bank, 
Savings & Loan, Credit Union, or Financial Institution	Account Number	
Account Balance
As of	
mmddyyyy	
13a	$ 	
13b	$ 	
13c	$	
13d	Total Cash (Add lines 13a through 13c, and amounts from any attachments)	$	
INVESTMENTS  Include stocks, bonds, mutual funds, stock options, certificates of depo\
sit, and retirement assets such as IRAs, Keogh, and 401(k) 
plans. Include all corporations, partnerships, limited liability compani\
es, or other business entities in which you are an officer, director, ow\
ner, 
member, or otherwise have a financial interest.	
Type of Investment  
or Financial Interest	Full Name & Address  
(Street, City, State, ZIP code) of Company	Current Value	
Loan Balance (if applicable)
As of	mmddyyyy	
Equity  
Value minus Loan	
14a	
Phone	$ 	$ 	$ 	
14b	
Phone	$ 	$ 	$ 	
14c	
Phone	$ 	$ 	$ 	
14d	Total Equity (Add lines 14a through 14c and amounts from any attachments)	$	
AVAILABLE CREDIT  Include all lines of credit and bank issued credit cards.   
Full Name & Address (Street, City, State, ZIP code) of Credit Institution	Credit Limit	
Amount Owed
As of	
mmddyyyy	
Available Credit
As of	
mmddyyyy	
15a	
Acct. No	$ 	$ 	$ 	15b	
Acct. No	$ 	$ 	$ 	
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 ( Term Life insurance does not have a cash value)	
Yes	NoIf 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	$

Form 433-A (Rev. 12-2012)            Page  	3	
REAL PROPERTY Include all real property owned or being purchased	
Purchase Date 
(mmddyyyy)	Current Fair 
Market Value  (FMV)	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) and County	Lender/Contract Holder Name, Address (Street, City, State, ZIP code), and Phone	
Phone
    
                         	17b   Property Description	
$	$	$	$	Location (Street, City, State, ZIP code) and County	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, trai\
lers, etc.
Description (Year, Mileage, Make/Model,  
Tag Number, Vehicle Identification Number)
18a  Year	Make/Model	
Mileage	License/Tag Number	
Vehicle Identification Number	
Purchase/
Lease Date 
(mmddyyyy)	Current Fair 
Market Value  (FMV)
$	
Current Loan Balance
$	
Amount of 
Monthly Payment	
$	
Date of Final  Payment 
(mmddyyyy)	Equity  
FMV Minus Loan	
$
Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone
Phone	
18b  Year	Make/Model	
Mileage	License/Tag Number	
Vehicle Identification Number	
$	$	$	$
Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone
Phone	
18c	Total Equity (Add lines 18a, 18b and amounts from any attachments) 	$	
Purchase/
Lease Date 
(mmddyyyy)	Current Fair 
Market Value  (FMV)	Current Loan Balance	Amount of 
Monthly Payment	Date of Final  Payment 
(mmddyyyy)	Equity  
FMV Minus Loan	
19a  Property Description	
$	$	$	$	
Location (Street, City, State, ZIP code) and County Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone
Phone
     
                               	
19b  Property Description	
$	$	$	$	
Location (Street, City, State, ZIP code) and County Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone
Phone	
19c	Total Equity (Add lines 19a, 19b and amounts from any attachments) 	$
Form 	433-A	 (Rev. 12-2012)	
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, m\
ining claims, etc.

Form 433-A (Rev. 12-2012)            Page  	4	
If you are self-employed, sections 6 and 7 must be completed before cont\
inuing.	
Section 5: Monthly Income and Expenses
Monthly Income/Expense Statement (For additional information, refer to Publication 1854.)	
Total Income	
Source	Gross Monthly	
20   Wages (Taxpayer) 	1	$ 	
21   Wages (Spouse)  	1	$	
22   Interest - Dividends	$	
23   Net Business Income 	2	$	
24   Net Rental Income 	3	$ 	
25   Distributions (K-1, IRA, etc.) 	4	$	
26   Pension (Taxpayer)	$	
27   Pension (Spouse)	$	
28   Social Security (Taxpayer) 	$ 	
29   Social Security (Spouse)	$	
30   Child Support	$	
31   Alimony	$ 	
       Other Income (Specify below) 	5	
32	$ 	
33	$ 	
34   Total Income (add lines 20-33)	$ 	
Total Living Expenses	
Expense Items 	6	Actual Monthly	
35   Food, Clothing and Misc. 	7	$ 	
36   Housing and Utilities 	8	$	
37   Vehicle Ownership Costs 	9	$	
38   Vehicle Operating Costs 	10	$	
39   Public Transportation 	11	$ 	
40   Health Insurance	$	
41   Out of Pocket Health Care Costs 	12	$	
42   Court Ordered Payments	$	
43   Child/Dependent Care	$ 	
44   Life Insurance	$	
45   Current year taxes (Income/FICA) 	13	$	
46   Secured Debts (Attach list)	$	
47   Delinquent State or Local Taxes 	$ 	
48   Other Expenses (Attach list)	$	
49   Total Living Expenses (add lines 35-48)	$	
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 pay\
ments, 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 = $2,11\
0.22
If paid semimonthly (twice each month) - multiply semimonthly gross wages by 2. Example: $856.23 x 2 = $1,712.4\
6	
2 Net Income from Business: Enter monthly net business income. This is the amount earned after ordin\
ary 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 ne\
gative 
number. If this amount is more or less than previous years, attach an ex\
planation. 
3 Net Rental Income: Enter monthly net rental income. This is the amount earned after ordinar\
y and necessary monthly rental expenses are  
paid. Do not include deductions for depreciation or depletion. If the ne\
t rental income is a loss, enter “0.” Do not enter a negative numb\
er.
4 Distributions: Enter the total distributions from partnerships and subchapter S corpora\
tions reported on Schedule K-1, and from limited  
liability companies reported on Form 1040, Schedule C, D or E. Enter tot\
al distributions from IRAs if not included under pension income.
5 Other Income: Include agricultural subsidies, unemployment compensation, gambling inco\
me, oil credits, rent subsidies, etc.
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 unsecur\
ed 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 produ\
cts for one month. The 
miscellaneous allowance is for expenses incurred that are not included i\
n 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 aver\
age monthly expenses for the following:  
property taxes, homeowner’s or renter’s insurance, maintenance, du\
es, fees, and utilities. Utilities include gas, electricity, water, fuel\
, oil, 
other fuels, trash collection, telephone, cell phone, cable television a\
nd internet services.
9	
Vehicle Ownership Costs: Total of monthly lease or purchase/loan payments.	
10	Vehicle Operating Costs: Total of maintenance, repairs, insurance, fuel, registrations, licenses,\
 inspections, parking, and tolls for one month.	
11	Public Transportation: Total of monthly fares for mass transit (e.g., bus, train, ferry, taxi, etc.)	
12	Out of Pocket Health Care Costs: Monthly total of medical services, prescription drugs and medical suppli\
es  (e.g., eyeglasses, hearing aids, etc.)	
13	Current Year Taxes: Include state and Federal taxes withheld from salary or wages, or paid a\
s estimated taxes.
Certification: Under penalties of perjury, I declare that to the best of my knowledge a\
nd 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 ve\
rification 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)	
Form 	433-A	 (Rev. 12-2012)

Form 433-A (Rev. 12-2012)            Page  	5	
Sections 6 and 7 must be completed only if you are SELF-EMPLOYED.	
Section 6: Business Information
51
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, part\
nerships or corporations, must complete Form 433-B.
Business Name & Address (if different than 1b)	52
53	Employer Identification Number	54	Type of Business	Is the business a  
Federal Contractor	
Yes	No	
56	Business Website (web address)	57	Total Number of Employees	58	Average Gross Monthly Payroll	
59	Frequency of Tax Deposits	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, etc.) Name & Address (Street, City, State, ZIP code)	Payment Processor Account Number	
61a
61b
CREDIT CARDS ACCEPTED BY THE BUSINESS	
Credit Card	Merchant Account Number	Issuing Bank Name & Address (Street, City, State, ZIP code)	
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	Full name & Address (Street, City, State, ZIP code)  
of Bank,Savings & Loan, Credit Union or Financial Institution.	Account Number	
Account Balance 
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 b\
artering or online auction accounts.  
(List all contracts separately, including contracts awarded, but not st\
arted.)  Include Federal, state and local government grants and contracts.
Accounts/Notes Receivable & Address (Street, City, State, ZIP code)	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)	$	
Form 	433-A	 (Rev. 12-2012)	
55

Form 433-A (Rev. 12-2012)            Page  	6	
Section 7: Sole Proprietorship Information (lines 67 through 87 should reconcile with business Profit and Loss Sta\
tement)	
Form 	433-A	 (Rev. 12-2012)	
BUSINESS ASSETS   Include all tools, books, machinery, equipment, inventory or other asset\
s 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)	Current Fair 
Market Value  (FMV)	Current Loan Balance	Amount of 
Monthly Payment	Date of Final  Payment 
(mmddyyyy)	Equity  
FMV Minus Loan	
66a    Property Description	
$	$	$	$	
Location (Street, City, State, ZIP code) and Country	Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code), and Phone	
Phone
     
                              	
66b    Property Description	
$	$	$	$	
Location (Street, City, State, ZIP code) and Country	Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code), and Phone	
Phone	
66c	Total Equity (Add lines 66a, 66b and amounts from any attachments)	$	
Section 7 should be completed only if you are SELF-EMPLOYED	
Accounting Method Used: 	Cash	Accrual	
Income and Expenses during the period (mmddyyyy)	to (mmddyyyy)	
Total Monthly Business Income
Source	Gross Monthly	
67   Gross Receipts	$ 	
68   Gross Rental Income	$	
69   Interest	$	
70   Dividends	$	
71   Cash Receipts not included in lines 67-70	$ 	
Other Income (Specify below)	
72	$	
73	$	
74	$ 	
75	$	
76   Total Income (Add lines 67 through 75)	$	
   Total Monthly Business Expenses (Use attachments as needed)	
Expense Items	Actual Monthly	
77   Materials Purchased 	1	$ 	
78   Inventory Purchased 	2	$	
79   Gross Wages & Salaries	$	
80   Rent	$	
81   Supplies 	3	$ 	
82   Utilities/Telephone 	4	$	
83   Vehicle Gasoline/Oil	$	
84   Repairs & Maintenance	$	
85   Insurance	$ 	
86   Current Taxes 	5	$	
87   	Other Expenses, including installment payments	 
(Specify)$	
88   Total Expenses (Add lines 77 through 87)	$	
89   Net Business Income (Line 76 minus 88) 	6	$ 	
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 
production of a product or service.
2   Inventory Purchased: Goods bought for resale.
3   Supplies: Supplies are items used in the business that are  
consumed or used up within one year. This could be the cost of books, 
office supplies, professional equipment, etc.
4   Utilities/Telephone: Utilities include gas, electricity, water, oil, other 
fuels, trash collection, telephone, cell phone and business internet. 5   Current Taxes: Real estate, excise, franchise, occupational, 
personal property, sales and employer’s portion of employment taxes.
6   Net Business Income: Net profit from Form 1040, Schedule C may 
be used if duplicated deductions are eliminated (e.g., expenses for 
business use of home already included in housing and utility expenses 
on page 4). Deductions for depreciation and depletion on Schedule C 
are not cash expenses and must be added back to the net income 
figure. In addition, interest cannot be deducted if it is already includ\
ed in 
any other installment payments allowed.	
IRS USE ONLY (Notes) 
  
 
Use the prior 3, 6, 9 or 12 month period to determine your typical busin\
ess income and expenses.
Provide a breakdown below of your average monthly income and expenses, b\
ased on the period of time used above.