Form 433-F - Collection Information Statement - Department Of Treasury Page 2

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D. CREDIT CARDS

(Visa, MasterCard, American Express, Department Stores, etc.)

Type

Credit Limit

Balance Owed

Minimum Monthly Payment

E. WAGE INFORMATION

(If you have more than one employer, include the information on another sheet of paper.)

)

Your Employer (name and address)

Spouse's Employer (name and address

Paid monthly (once each month)

Paid bi-weekly (every two weeks)

)

Paid semi-monthly (two times each month

Paid semi-monthly (two times each month)

Paid weekly

ATTACHMENTS REQUIRED: Provide COPIES of pay stubs or earnings statements for the past 3 months from

each employer. You may send year-to-date information as long as a minimum of 3 months is represented.

F. NON-WAGE HOUSEHOLD INCOME

(List monthly amounts. For Self-Employment and Rental Income, list the monthly amount received after

expenses.)

Alimony Income:

Net Rental Income:

Interest Income:

Social Security Income:

Child Support Income:

Unemployment Income:

Net Self-Employment Income:

Pension Income:

Other:

G. MONTHLY NECESSARY LIVING EXPENSES

(List monthly amounts. For expenses paid other than monthly, see instructions.)

1. Food / Personal Care

3. Housing & Utilities

5. Other

Rent:

Child / Dependent Care:

Food:

Housekeeping Supplies:

Electricity:

Estimated Tax Payments:

Clothing & Clothing Services:

Water:

Term Life Insurance:

Heat / Gas:

Personal Care Products & Services:

Retirement (Employer Required):

Telephone:

Misc. (Cable, Internet, etc.):

Retirement (Voluntary):

2. Transportation

Court Ordered Payments:

4. Medical

Gas / Parking / Tolls / Maintenance:

Health Insurance:

Public Transportation:

Prescription Drugs:

Vehicle Insurance:

Doctor Bills / Co-Pays:

ATTACHMENTS REQUIRED: For each expense listed in boxes 4 & 5 above, provide COPIES of cancelled

checks and or billing statements proving payment of the expense for the last 3 months, unless the payments

are already shown on wage statements you are attaching. For court ordered payments, also provide a COPY

of the court order.

H. ADDITIONAL INFORMATION

1. Number of dependents you can claim on this year's tax return (including yourself and your spouse):

2. Please explain any expected changes to future income or expenses:

Under penalty of perjury, I declare to the best of my knowledge and belief this statement of assets, liabilities and other information is true, correct and complete.

Your Signature

Date

Spouse’s Signature

Catalog 62053J

Form 433-F (EN/SP) (Rev. 3-2006)

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