Form 433-F - Collection Information Statement - Department Of Treasury
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2Form 433-F (EN/SP)
Department of the Treasury - Internal Revenue Service
Collection Information Statement
(Rev. 3-2006)
Name(s) and Address
Your Social Security Number or Individual Taxpayer Identification Number
Your Spouse’s Social Security Number or Individual Taxpayer Identification Number
Spouse’s Telephone Numbers
Your Telephone Numbers
(
)
(
)
Home:
Home:
County of Residence
(
)
(
)
Work:
Work:
(
)
(
)
Cell:
Cell:
A. ACCOUNTS / LINES OF CREDIT
(include Banks, Savings and Loans, Credit Unions, Certificates of Deposit, Individual Retirement Accounts
(IRAs), Keogh Plans, Simplified Employee Pensions, 401(k) Plans, Profit Sharing Plans, Mutual Funds and Stock Brokerage Accounts)
Type of Account
Name and Address of Institution
Current Balance / Value
ATTACHMENTS REQUIRED: Provide COPIES of monthly statements showing
detailed transactions for the last 3 months for each bank or credit union account.
B. REAL ESTATE
(home, vacation property, timeshares and other real estate)
County / Description
Monthly Payment(s)
Financing
Current Value
Balance Owed
Equity
Year Purchased
Purchase Price
Year Refinanced
Refinance Amount
Primary Residence
Other
Purchase Price
Year Purchased
Year Refinanced
Refinance Amount
Primary Residence
Other
Year Purchased
Purchase Price
Refinance Amount
Year Refinanced
Primary Residence
Other
C. OTHER ASSETS
(cars, boats, recreational vehicles, whole life policies, etc.)
Description
Monthly Payment
Year Purchased
Final Payment (mo / yr)
Balance Owed
Equity
Current Value
/
/
/
/
/
/
/
TURN PAGE TO CONTINUE
Catalog 62053J
Form 433-F (EN/SP) (Rev. 3-2006)
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