Form 433-F - Collection Information Statement - 2003
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1Department of the Treasury—I I n n t t e e r r n n a a l l R R e e v v e e n n u u e e S S e e r r v v i i c c e e
4 4 3 3 3 3 - - F F
Form
C C o o l l l l e e c c t t i i o o n n I I n n f f o o r r m m a a t t i i o o n n S S t t a a t t e e m m e e n n t t
(Rev. 02-2003)
Your name(s) and Address
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 A : : A A C C C C O O U U N N T T S S (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 B : : R R E E A A L L E E S S T T A A T T E E : : (home and other real estate)
County/Description
Value
Balance Owed
Equity
Monthly Payment
C C : : O O T T H H E E R R A A S S S S E E T T S S : : (cars, boats, recreational vehicles, whole life policies, etc.)
County/Description
Value
Balance Owed
Equity
Monthly Payment
D D : : C C R R E E D D I I T T C C A A R R D D S S : :
Type (e.g. VISA/Nations Bank)
Credit Limit
Balance Owed
Minimum Monthly Payment
E E : : M M O O N N T T H H L L Y Y I I N N C C O O M M E E : :
Your Gross Pay:
Spouse's Gross Pay:
Federal Tax Withholding:
Federal Tax Withholding:
Your Available Income:
State and Local Taxes:
State and Local Taxes:
Social Security Taxes:
Social Security Taxes:
Spouse's Available Income:
Retirement/Medicare:
Retirement/Medicare
Court Ordered Payments:
Court Ordered Payments:
Total Available Income:
Your Net Pay:
Spouse's Net Pay:
Other Income:
Other Income:
Your Available Income:
Your Available Income:
F F : : M M O O N N T T H H L L Y Y E E X X P P E E N N S S E E S S
G G : : A A D D D D I I T T I I O O N N A A L L I I N N F F O O R R M M A A T T I I O O N N
A A M M O O U U N N T T
I I R R S S U U S S E E
Rent:
Total Number of Dependents
(don't show mortgage here)
NATIONAL STANDARDS:
(include yourself and spouse)
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
INTERNAL REVENUE
Quarterly Payment of Estimated Taxes
(Form 1040ES)
SERVICE FOR YOUR
Life Insurance
(if NOT listed in Section C)
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
Cat. No. 62053J
Form 4 4 3 3 3 3 - - F F (Rev. 02-2003)
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