Collection Information Statement

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Form 433f: Collection Information Statement

Use Tax Form 433f: Collection Information Statement 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.

Collection Information Statement

Your Telephone Numbers

Spouse’s Telephone Numbers

Enter the number of people in the household who can be claimed on this year’s tax return including you and your spouse.
If you or your spouse are self employed or have self employment income, provide the following information:

A. ACCOUNTS / LINES OF CREDIT Include checking, online, mobile (e.g., PayPal) and savings accounts, Certificates of Deposit, Trusts, Individual Retirement Accounts (IRAs), Keogh Plans, Simplified Employee Pensions, 401(k) Plans, Profit Sharing Plans, Mutual Funds, Stocks, Bonds and other investments. If applicable, include business accounts. (Use additional sheets if necessary.)
Name and Address of InstitutionAccount NumberType of AccountCurrent Balance/ ValueCheck if Business Account
B. REAL ESTATE Include home, vacation property, timeshares, vacant land and other real estate. (Use additional sheets if necessary.)
Description/Location/CountyMonthly Payment(s)FinancingCurrent ValueBalance OwedEquity

C. OTHER ASSETS Include cars, boats, recreational vehicles, whole life policies, etc. Include make, model and year of vehicles and name of Life Insurance company in Description. If applicable, include business assets such as tools, equipment, inventory, etc. (Use additional sheets if necessary.)
DescriptionMonthly PaymentYear PurchasedFinal Payment (mo/yr)Current ValueBalance OwedEquity
D. CREDIT CARDS (Visa, MasterCard, American Express, Department Stores, etc.)
TypeCredit LimitBalance OwedMinimum Monthly Payment
E. BUSINESS INFORMATION Complete E1 for Accounts Receivable owed to you or your business. (Use additional sheets if necessary.) Complete E2 if you or your business accepts credit card payments.
E1. Accounts Receivable owed to you or your business
NameAddressAmount Owed
E2. Name of individual or business on account
Credit Card
(Visa, Master Card, etc.)
Issuing Bank Name and AddressMerchant Account Number
F. EMPLOYMENT INFORMATION If you have more than one employer, include the information on another sheet of paper. (If attaching a copy of current pay stub, you do not need to complete this section.)

How often are you paid? (Check one)

Taxes per pay period
How often are you paid? (Check one)

Taxes per pay period
G. NON-WAGE HOUSEHOLD INCOME List monthly amounts. For Self-Employment and Rental Income, list the monthly amount received after expenses or taxes and attach a copy of your current year profit and loss statement.
H. MONTHLY NECESSARY LIVING EXPENSES List monthly amounts. (For expenses paid other than monthly, see instructions.)
Actual Monthly ExpensesIRS Allowed
1Food / Personal Care See instructions. If you do not spend more than the standard allowable amount for your family size, fill in the Total amount only.
3Housing & Utilities

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