Form 433a - Collection Information Statement For Individuals - West Virginia State Tax Department

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West Virginia State Tax Department
Collection Information Statement For Individuals
Form 433A
(
Rev. Nov. 07)
(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
2. Home phone number
3. Marital status
(
)
b. Spouse's social security no.
4a. Taxpayer's SS No.
________
County
Section I.
Employment Information
5. Taxpayer's employer or business
a. How long employed
Business phone Number
c. Occupation
(name and address)
(
)
d. Number of exemptions
e. Pay period
f.
(Check appropriate
claimed on Form W-4
Weekly
Bi-weekly
box)
_______
Monthly
_________
Wage earner
Payday: ________ (Mon - Sun)
Sole proprietor
Partner
6. Spouse's employer or business
a. How long employed
b. Business phone number
c. Occupation
(name and address)
(
)
d. Number of exemptions
e. Pay period
f.
(Check appropriate
claimed on Form W-4
Weekly
Bi-weekly
box)
______
Monthly
_________
Wage earner
Payday: ________ (Mon - Sun)
Sole proprietor
Partner
Personal Information
SECTION II.
7. Name, address and telephone number of next of kin or
8. Other names or aliases
9. Previous address(es)
other reference
10. Age and relationship of dependents living in your household (exclude yourself and spouse)
11.
a. Taxpayer
12. Latest filed income tax
a. No. of
b. Adjusted Gross
Date
return (tax year)
exemptions
Income
of
claimed
b. Spouse
Birth
Section III.
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
Total
$
0.00
(Enter in Item 21)

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