Form 433-F - How To Prepare A Collection Information Statement


How to Prepare a
Collection Information Statement (Form 433-F)
Section F – Monthly Expenses
Please complete all of the blocks except for the shaded ones.
Write N/A (Not Applicable) for those blocks which don't apply to
Rent – Please enter your monthly rent payment. Write N/A (not
you. We need you to complete this form so we can establish the
applicable) if you own your home and pay mortgage expenses.
best method for you to pay the amount due.
National Standard Expenses (see National Standard Expenses
We've explained below some areas of the form which people have
Chart) – This category includes clothing and services, food,
found the most confusing to understand.
housekeeping supplies, personal care products and services, and
miscellaneous expenses. The chart allows you a certain amount
If any section is too small for the information you need to supply,
based on your total gross monthly income and the size of your
please use a separate sheet.
Section A –
You may want to claim a higher amount if you have special
circumstances. If you do so, please explain the special
circumstances and provide proof of your expenses.
Please include all accounts in Banks, Savings & Loan Institutions,
Certificates of Deposits, Individual Retirement Arrangements
Transportation – Please enter your average monthly transportation
(IRAs), Roth Individual Retirement Arrangements (IRAs), Keogh
expense. You may include costs such as insurance, registration
Plans, Simplified Employee Pensions, Mutual Funds, Stock
fees, maintenance, fuel, parking fees and tolls, and public
Brokerage Accounts, etc. Make a totally comprehensive listing of
transportation fares.
your accounts and enter all accounts, even it they currently have
no balance. However, do not enter bank loans in this section.
Medical – Please show only reoccurring medical expenses here.
Don't include a one time only medical expense.
Section B – Real Estate
Child Care/Dependent Care – Please enter the monthly amount
Please list all the real estate you own or are purchasing. This
you pay for the care of a dependent child or adult. Someone is your
listing should include your home and any other real estate you
dependent when you pay for more than half of their support.
own. Include the address and county description of any property
Quarterly Estimated Tax Payments (Form 1040ES) – Enter the
you list along with its current market value and amount you owe on
monthly amount you pay on your estimated tax.
In order to determine a property's equity, please subtract the
Life Insurance – Please show the expenses you pay for term life
amount owed on it from its current market value.
insurance or any other insurance you have not listed in Section C.
Section C – Other Assets
Add up all of the monthly expenses listed in Section F to get
the figure for Total Expenses.
Please list any cars, boats, recreational vehicles, whole life
policies, or other assets that you own.
Section G – Additional Information
Complete this section the same way you completed section B:
Please show the total number of dependents in your family. Include
subtract any loans you owe on an asset from its market value.
yourself and your spouse.
The amount remaining after you do this is your equity in the asset.
Enter the maximum amount you would like to pay each month
on your account.
Section D – Credit Cards
Please enter all the credit cards for which you have an account.
Enter credit cards issued by a bank, credit union, or savings and
loan institution (MasterCard, Visa, Discover, overdraft protection,
Both yourself and your spouse need to sign the Collection
etc.). List all other charge accounts such as department stores
Information Statement when the tax liability is joint. When both of
and oil companies.
you have signed the same tax return, and both of you agree that
Section E – Monthly Income
you owe the money, you should both sign the statement.
Please enter the total amount of your monthly wages or salary
(your gross pay) - do not subtract taxes paid. (Include all income
from those living in your household who are not qualified
You can list the taxes withheld from your paycheck on the lines
under the Gross Pay line.
Subtract the taxes withheld from your gross pay and you'll get the
correct amount for your Net Pay.
Please also include the amount from all other sources of income
and add it to your net income to get your available income. Do the
same for your spouse, if you have one. List these expenses in
Section C and Section F.
Form 433-F (Rev. 08-2005)


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