Form 433-A - How To Prepare Form 433-A And Templates Page 3

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Form 433A
*Rev- Nov- 07)
f
West Virginia State Tax Department
PrInt
Collection Information Statement For Individuals
(If you need additional space, please attach a separate sheet)
Complete all blocks, except shaded areas. Write "N/A" (non applicable) in those blocks that do not apply.
1. Taxpayer(s) name and address
Jason and Julie Myname
1536 Road Dr
Charleston WV 25301
COunty Kanawha
2. Home phone number
( 304) 345-0000
4a. Taxpayer's SS No.
000-00-0000
3. Marital status
Maried
b. Spouse's social security no.
111-11-1111
Section I.
Employment Information
5. Taxpayer's employer or business
(name and address)
My Job USA
1219 Kanawha Blvd
Charleston, WV 25301
a. How long employed
2yrs
d. Number of exemptions
claimed on Form W-4
1
Business phone Number
( 304)
555-5555
e. Pay period
Weekly
/ Bi-weekly
Monthly
Payday:
(Mon - Sun)
c. Occupation
Machinist
f. (Check appropriate
box)
/ Wage earner
Sole proprietor
Partner
6
Spouse's employer or business
(name and address)
Spouse Job
30 Main St.
Dunbar.WV 25044
a. How long employed
3yrs
b. Business phone number
( 304)
666-6666
c. Occupation
Cashier
d. Number of exemptions
claimed on Form W-4
1
e. Pay period
Weekly
/ Bi-weekly
Monthly
Payday:
(Mon - Sun)
f. (Check appropriate
box)
/ Wage earner
Sole proprietor
Partner
SECTION II.
Personal Information
7. Name, address and telephone number of next of kin or
other reference
Debby Myname-Chas WV 305-555-3333
8. Other names or aliases
n/a
9. Previous address(es)
same
10
Age and relationship of dependents living in your household (exclude yourself and spouse)
David-son--age 12
11.
Date
of
Birth
a. Taxpayer
2/2/70
b. Spouse
5/12/72
12. Latest filed income tax
return (tax year)
2010
a. No. of
exemptions
claimed
b
Adjusted Gross
Income
62,000.00
Section
General Financial Information
13
Bank accounts (include savings & loans, credit unions. IRA and retirement plans, certificates of deposit, etc.) Enter bank loans in item 28.
Name of Institution
Address
Type of Acct.
Acct. #
Balance
BB&T
Lee St Charleston WV
Checking
53261112
300.00
Total (Enter in Item 21)
D
300.00

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