Collection Information Statement

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
Name(s) and Address				Your Social Security Number or Individual Taxpayer Identification Number
				Your Spouse’s Social Security Number or Individual Taxpayer Identification Number
If address provided above is different than last return filed, please check here				Your Telephone Numbers Home: Work: Cell:		Spouse’s Telephone Numbers Home: Work: Cell:
County of Residence
Enter the number of people in the household who can be claimed on this year’s tax return including you and your spouse. Under 65 65 and Over
If you or your spouse are self employed or have self employment income, provide the following information:
Name of Business		Business EIN		Type of Business		Number of Employees (not counting owner)
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 Institution		Account Number		Type of Account		Current Balance/ Value	Check if Business Account






B. REAL ESTATE Include home, vacation property, timeshares, vacant land and other real estate. (Use additional sheets if necessary.)
Description/Location/County		Monthly Payment(s)	Financing		Current Value	Balance Owed	Equity
Primary Residence Other			Year Purchased	Purchase Price
			Year Purchased	Purchase Price
Primary Residence Other			Year Purchased	Purchase Price
			Year Purchased	Purchase Price
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.)
Description		Monthly Payment	Year Purchased	Final Payment (mo/yr)	Current Value	Balance Owed	Equity
				/
				/
				/
				/
				/
				/
D. CREDIT CARDS (Visa, MasterCard, American Express, Department Stores, etc.)
Type		Credit Limit		Balance Owed		Minimum Monthly Payment




TURN PAGE TO CONTINUE
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
Name		Address				Amount Owed


List total amount owed from additional sheets
Total amount of accounts receivable available to pay to IRS now
E2. Name of individual or business on account

Credit Card (Visa, Master Card, etc.)		Issuing Bank Name and Address				Merchant 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.)
Your current Employer (name and address)				Spouse’s current Employer (name and address)
How often are you paid? (Check one) Weekly Biweekly Semi-monthly Monthly Gross per pay period Taxes per pay period (Fed) (State) (Local) How long at current employer				How often are you paid? (Check one) Weekly Biweekly Semi-monthly Monthly Gross per pay period Taxes per pay period (Fed) (State) (Local) How long at current employer
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.
Alimony Income		Net Rental Income			Interest/Dividends Income
Child Support Income		Unemployment Income			Social Security Income
Net Self Employment Income		Pension Income			Other:
H. MONTHLY NECESSARY LIVING EXPENSES List monthly amounts. (For expenses paid other than monthly, see instructions.)
				Actual Monthly Expenses		IRS Allowed
1	Food / 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.
	Food
	Housekeeping Supplies
	Clothing and Clothing Services
	Personal Care Products & Services
	Miscellaneous
	Total
2	Transportation
	Gas / Insurance / Licenses / Parking / Maintenance etc.
	Public Transportation
	Total
3	Housing & Utilities
	Rent
	Electric, Oil/Gas, Water/Trash
	Telephone/Cell/Cable/Internet
	Real Estate Taxes and Insurance (if not included in B above)
	Maintenance and Repairs
	Total
4	Medical
	Health Insurance Out of Pocket Health Care Expenses
	Out of Pocket Health Care Expenses
	Total
5	Other
	Child / Dependent Care
	Estimated Tax Payments
	Term Life Insurance
	Retirement (Employer Required)
	Retirement (Voluntary)
	Union Dues
	Delinquent State & Local Taxes (minimum payment)
	Student Loans (minimum payment)
	Court Ordered Child Support
	Court Ordered Alimony
	Other Court Ordered Payments
	Other (specify)
	Other (specify)
	Other (specify)
	Total

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