Form 433-F - Collection Information Statement - 2005
Download a blank fillable Form 433-F - Collection Information Statement - 2005 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 433-F - Collection Information Statement - 2005 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1433-F
Form
Department of the Treasury — Internal Revenue Service
Collection Information Statement
(Rev. 08-2005)
Your name(s) and Address (Include the County you live in)
Your Social Security Number
Your Spouse's Social Security Number
Area Code and Telephone Numbers
Home:
Your Work:
Your Spouse's Work:
Your Employer or Business (name and address)
Your Spouse's Employer or Business (name and address)
A: ACCOUNTS (include Banks, Savings and Loans, Credit Union, Certificates of Deposits, Individual Retirement Arrangements (IRAS), Roth
Individual Retirement Arrangements (IRAs), Keogh Plans, Simplified Employee Pensions, Mutual Funds, and Stock Brokerage Accounts)
Name of Institution
Address
Type of Account
Balance
B. REAL ESTATE: (home and other real estate)
Value
Monthly Payment
County/Description
Balance Owed
Equity
C. OTHER ASSETS: (cars, boats, recreational vehicles, whole life policies, etc.)
Balance Owed
County/Description
Value
Equity
Monthly Payment
D. CREDIT CARDS:
Balance Owed
Credit Limit
Type (e.g. VISA/Nations Bank)
Minimum Monthly Payment
E. MONTHLY INCOME:
Your Gross Pay:
Spouse's Gross Pay:
Federal Tax Withholding:
Federal Tax Withholding:
Your Available Income:
State and Local Taxes:
State and Local Taxes:
Spouse's Available Income:
Social Security Taxes:
Social Security Taxes:
Retirement/Medicare:
Retirement/Medicare:
0
Court Ordered Payments:
Court Ordered Payments:
Other Household Income:
(Not a qualified dependent)
Your Net Pay:
Spouse's Net Pay:
0
Other Income:
Other Income:
Total Available Income:
Your Available Income:
Your Available Income:
G. ADDITIONAL
F. MONTHLY EXPENSES:
INFORMATION
AMOUNT
IRS USE
Total Number of Dependents
Rent:
(don't show mortgage here)
(include yourself and spouse)
NATIONAL STANDARDS:
food, household/personal
needs, miscellaneous (See instructions)
Expected Changes to Income, Health Expenses, ETC.
Utilities
(electricity, water, heat, telephone)
Transportation
(gas, bus fare, car insurance, etc.)
Medicine (health insurance, drugs, doctor bills)
$
MONTHLY AMOUNT YOU
Child/Dependent Care Costs
PROPOSE TO PAY THE
Quarterly Payment of Estimated Taxes
(Form 1040ES)
INTERNAL REVENUE SERVICE
Life Insurance
(if NOT listed in Section C)
FOR YOUR ACCOUNT:
Other Deductions or Expenses NOT listed
1
FOR IRS USE ONLY (Sections B, C, D, and F)
2
TOTAL ALLOWABLE EXPENSES:
3
MONTHLY PAYMENT AMOUNT
TOTAL EXPENSES
Under penalties 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
Spouse's Signature
Date
Form 433-F (Rev. 08-2005)
Cat. No. 62053J
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial