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Form 433a: Collection Information Statement for Wage Earners and Self-Employed Individuals

Use Tax Form 433a: Collection Information Statement for Wage Earners and Self-Employed Individuals as a stand alone tax form calculator to quickly calculate specific amounts for your 2018 tax return. Form 433a: Collection Information Statement for Wage Earners and Self-Employed Individuals is also integrated into our comprehensive US Tax Calculator where you can complete and save your calculations for later use. Alternatively you can use one of our Combined Federal and State Tax Estimator to quickly calculate your salary, tax and take home pay.

Current Fair Market Value (FMV)
Collection Information Statement for Wage Earners and Self-Employed Individuals
Section 1: Personal Information
1a1c1d
1b1e1f
2b
2aMarital Status:
3a Taxpayer
3b 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.
TaxpayerSpouse
4a5a
4b5b
4c4d &emsp 5c5d
Yes   No Yes   No
4e4f   5e5f
(years) (years) (years) (years)
4g4h   5g5h
Weekly   Bi-weekly
Monthly   Other
Weekly   Bi-weekly
Monthly   Other
Section 3: Other Financial Information (Attach copies of applicable documentation)
6 (If yes, answer the following) Yes   No




$


7 (If yes, answer the following) Yes   No





8 (If yes, answer the following) Yes   No
9a (If yes, answer the following) Yes   No

$

9b Yes   No
10 (If yes, answer the following) Yes   No

$

$
11 (If yes, answer the following) Yes   No

$

$

$
Section 4: Personal Asset Information for All Individuals
12CASH ON HAND Include cash that is not in a bank
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.).
Type of AccountFull Name & Address (Street, City, State, ZIP code) of Bank, Savings & Loan, Credit Union, or Financial InstitutionAccount NumberAccount Balance As of mmddyyyy
13a$
13b$
13c$
13d$
INVESTMENTS Include stocks, bonds, mutual funds, stock options, certificates of deposit, and retirement assets such as IRAs, Keogh, and 401(k) plans. 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 InterestFull Name & Address
(Street, City, State, ZIP code) of Company
Current ValueLoan Balance (if applicable) As of mmddyyyyEquity
Value minus Loan
14aPhone $$$
14bPhone $$$
14cPhone $$$
14d$
AVAILABLE CREDIT Include all lines of credit and bank issued credit cards. Full Name & Address (Street, City, State, ZIP code) of Credit InstitutioCurrent ValueAmount Owed
As of mmddyyyy
Available Credit As of mmddyyyy
15a
$$$
15b
$$$
15c$
16aLIFE INSURANCE Do you own or have any interest in any life insurance policies with cash value (Term Life insurance does not have a cash value)
  If yes, complete blocks 16b through 16f for each policy.
16b
16c
16d
16e$$$
16f$$$
16g$
Purchase Date (mmddyyyy)Current Loan BalanceAmount of Monthly PaymentDate of Final Payment (mmddyyyy)Equity
FMV Minus Loan
17a
$$$$

17b
$$$$

17c$
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)Purchase/Lease Date (mmddyyyy)Current Fair Market Value (FMV)Current Loan BalanceAmount of Monthly PaymentDate of Final Payment (mmddyyyy)Equity
FMV Minus Loan
18a

$$$$





18b

$$$$





18c$
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 BalanceAmount of Monthly PaymentDate of Final Payment (mmddyyyy)Equity
FMV Minus Loan
19a
$$$$

19b
$$$$

19c$
If you are self-employed, sections 6 and 7 must be completed before continuing.
Section 5: Monthly Income and Expenses
Monthly Income/Expense Statement (For additional information, refer to Publication 1854.)
Total IncomeTotal Living ExpensesIRS USE ONLY
SourceGross MonthlyExpense ItemsActual MonthlyAllowable Expenses
20$35$
21$36$
22$37$
23$38$
24$39$
25$40$
26$41$
27$42$
28$43$
29$44$
30$45$
31$46$
Other Income (Specify below)47$
32$48$
33$49$
34$50$
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 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, etc.
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.
Sections 6 and 7 must be completed only if you are SELF-EMPLOYED.
Section 6: Business Information
51Is the business a sole proprietorship (filing Schedule C)  
All other business entities, including limited liability companies, partnerships or corporations, must complete Form 433-B.
52
53
54
55Is the business a Federal Contractor  
56
57
58
59
60Does the business engage in e-Commerce (Internet sales) If yes, complete lines 61a and 61b  
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 CardMerchant Account NumberIssuing Bank Name & Address (Street, City, State, ZIP code)
62a
62b
62c
63$
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 AccountFull name & Address (Street, City, State, ZIP code) of Bank,Savings & Loan, Credit Union or Financial InstitutionAccount NumberAccount Balance
As of mmddyyyy
64a$
64b$
64c$
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)Status (e.g., age, factored, other)Date Due (mmddyyyy)Invoice Number or Government Grant or Contract NumberAmount Due
65a$
65b$
65c$
65d$
65e$
65f$
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)Current Fair Market Value (FMV)Current Loan BalanceAmount of Monthly PaymentDate of Final Payment (mmddyyyy)Equity
FMV Minus Loan
66a
$$$$

66b
$$$$

66c$
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:
Use the prior 3, 6, 9 or 12 month period to determine your typical business income and expenses.
Provide a breakdown below of your average monthly income and expenses, based on the period of time used above.
Total Monthly Business IncomeTotal Monthly Business Expenses (Use attachments as needed)
SourceGross MonthlyExpense ItemsActual Monthly
67$77$
68$78$
69$79$
70$80$
71$81$
Other Income (Specify below)82$
72$83$
73$84$
74$85$
75$86$
76$87$
88$
89$
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.
1Materials Purchased: Materials are items directly related to the production of a product or service.
2Inventory Purchased: Goods bought for resale.
3Supplies: 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.
4Utilities/Telephone: Utilities include gas, electricity, water, oil, other fuels, trash collection, telephone, cell phone and business internet.
5Current Taxes: Real estate, excise, franchise, occupational, personal property, sales and employer’s portion of employment taxes.
6Net 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 included in any other installment payments allowed.

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