Collection Information Statement for Wage Earners and Self-Employed Individuals

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 2024 tax return. 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
1a	Full Name of Taxpayer and Spouse (if applicable)		1c	Home Phone		1d	Cell Phone
1b	Address (Street, City, State, ZIP code) (County of Residence)		1e	Business Phone		1f	Business Cell Phone
			2b	Name, Age, and Relationship of dependent(s)
2a	Marital Status: Married   Unmarried (Single, Divorced, Widowed)
3a Taxpayer	Social Security No. (SSN)	Date of Birth (mmddyyyy)	Driver's License Number and State
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.
Taxpayer			Spouse
4a	Taxpayer's Employer Name		5a	Spouse's Employer Name
4b	Address (Street, City, State, and ZIP code)		5b	Address (Street, City, State, and ZIP code)
4c	Work Telephone Number	4d &emsp Does employer allow contact at work	5c	Work Telephone Number		5d	Does employer allow contact at work
		Yes   No					Yes   No
4e	How long with this employer	4f   Occupation	5e	How long with this employer		5f	Occupation
	(years) (years)			(years) (years)
4g	Number of withholding allowances claimed on Form W-4	4h   Pay Period:	5g	Number of withholding allowances claimed on Form W-4		5h	Pay Period:
		Weekly   Bi-weekly Monthly   Other					Weekly   Bi-weekly Monthly   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 $
11	In the past 10 years, have you transferred any assets for less than their 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 $
Section 4: Personal Asset Information for All Individuals
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) 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) 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 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 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 Institutio					Current Value	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   No   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)						$
			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) 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, trailers, etc.
Description (Year, Mileage, Make/Model, 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
18a	Year	Make/Model		$	$	$		$
Mileage		License/Tag Number		Lender/Contract Holder Name, Address (Street, City, State, ZIP code), and Phone Phone
Vehicle Identification Number
18b	Year	Make/Model		$	$	$		$
Mileage		License/Tag Number		Lender/Contract Holder Name, Address (Street, City, State, ZIP code), and Phone Phone
Vehicle Identification Number
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	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/Contract Holder Name, Address (Street, City, State, ZIP code), and Phone
				Phone
19b	Property Description			$	$	$		$
Location (Street, City, State, ZIP code) and County				Lender/Contract Holder Name, Address (Street, City, State, ZIP code), and Phone
				Phone
19c	Total Equity (Add lines 19a, 19b and amounts from any attachments)						$
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 Income				Total Living Expenses				IRS USE ONLY
Source			Gross Monthly	Expense Items			Actual Monthly	Allowable Expenses
20	Wages (Taxpayer)		$	35	Food, Clothing and Misc.		$
21	Wages (Spouse)		$	36	Housing and Utilities		$
22	Interest - Dividends		$	37	Vehicle Ownership Costs		$
23	Net Business Income		$	38	Vehicle Operating Costs		$
24	Net Rental Income		$	39	Public Transportation		$
25	Distributions (K-1, IRA, etc.)		$	40	Health Insurance		$
26	Pension (Taxpayer)		$	41	Out of Pocket Health Care Costs		$
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)		$
31	Alimony		$	46	Secured Debts (Attach list)		$
	Other Income (Specify below)			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)		$
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 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, 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 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	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 supplies (e.g., eyeglasses, hearing aids, etc.)
13	Current 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
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, partnerships or corporations, must complete Form 433-B.
52	Business Name & Address (if different than 1b)
53	Employer Identification Number		54	Type of Business		55	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 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 Number	Amount Due
65a							$
65b							$
65c							$
65d							$
65e							$
65f	Total Outstanding Balance (Add lines 65a through 65e and amounts from any attachments)						$
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 Balance	Amount of Monthly Payment	Date of Final Payment (mmddyyyy)	Equity FMV Minus Loan
66a	Property Description			$	$	$		$
Location (Street, City, State, ZIP code) and County				Lender/Contract Holder Name, Address (Street, City, State, ZIP code), and Phone
				Phone
66b	Property Description			$	$	$		$
Location (Street, City, State, ZIP code) and County				Lender/Contract Holder 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
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 (Use attachments as needed)
Source			Gross Monthly		Expense Items			Actual Monthly
67	Gross Receipts		$		77	Materials Purchased		$
68	Gross Rental Income		$		78	Inventory Purchased		$
69	Interest		$		79	Gross Wages & Salaries		$
70	Dividends		$		80	Rent		$
71	Cash Receipts not included in lines 67-70		$		81	Supplies		$
	Other Income (Specify below)				82	Utilities/Telephone		$
72			$		83	Vehicle Gasoline/Oil		$
73			$		84	Repairs & Maintenance		$
74			$		85	Insurance		$
75			$		86	Current Taxes		$
76	Total Income (Add lines 67 through 75)		$		87	Other Expenses, including installment payments (Specify)		$
					88	Total Expenses (Add lines 77 through 87)		$
					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 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 included in any other installment payments allowed.

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