Form Md 433-A - Collection Information Statement For Individuals

Form Md 433-A - Collection Information Statement For Individuals - 2000

MD 433-A

Form

(Rev. July 2000)

Collection Information Statement for Individuals

State of Maryland

(If you need additional space, please attach a separate sheet)

Comptroller of Maryland

Note: Complete all blocks, except shaded areas. Write “N/A” (not applicable) in those blocks that do not apply.

1 Taxpayer(s) name(s) and address

2 Home phone number

3 Marital status

(

)

4a Taxpayer’s Social Security number

4b Spouse’s Social Security number

County ______________________

Section I

Employment Information

5 Taxpayer’s employer or business

a How long employed

b Business phone number

c Occupation

(name and address)

e Pay period: ! Weekly

! Bi-weekly

d Number of exemptions

f (Check appropriate box)

! Monthly

! ________

! Wage earner

claimed on W-4

! Sole proprietor

! Partner

Payday: ___________ (Mon-Sun)

6 Spouse’s employer or business

a How long employed

b Business phone number

c Occupation

(name and address)

e Pay period: ! Weekly

! Bi-weekly

d Number of exemptions

f (Check appropriate box)

! Monthly

! ________

! Wage earner

claimed on W-4

! Sole proprietor

! Partner

Payday: ___________ (Mon-Sun)

Section II

Personal Information

7 Name, address and telephone number of

8 Other names or aliases

9 Previous address(es)

next of kin or other reference

10 Age and relationship of dependents living in your household (exclude yourself and spouse)

11 Date

a Taxpayer

b Spouse

12 Last filed income

a Number of exemptions

b Adjusted gross income

of birth

tax return (tax year)

claimed

Section III

General Financial Information

13 Bank accounts (include savings and loans, credit unions, IRA and retirement plans, certificates of deposit, etc.)

Name of Institution

Address

Type of Account

Account No.

Balance

Total (Enter in Item 21) ..................................................................................................................................................................................

Form Md 433-A - Collection Information Statement For Individuals - 2000

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