Form 433-A (Oic) - Collection Information Statement For Wage Earners And Self-Employed Individuals
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8Department of the Treasury — Internal Revenue Service
433-A (OIC)
Form
Collection Information Statement for Wage Earners and
(Rev. March 2017)
Self-Employed Individuals
Use this form if you are
►
An individual who owes income tax on a Form 1040, U.S.
►
An individual who is personally responsible for a partnership
Individual Income Tax Return
liability (only if the partnership is submitting an offer)
►
An individual who operates as a disregarded single member
►
An individual with a personal liability for Excise Tax
Limited Liability Company (LLC) taxed as a sole proprietor
►
An individual responsible for a Trust Fund Recovery Penalty
►
An individual who is submitting an offer on behalf of a
deceased person
►
An individual who is self-employed or has self-employment
income. You are considered to be self-employed if you are in
business for yourself, or carry on a trade or business.
Note: Include attachments if additional space is needed to respond completely to any question. This form should only be used with the Form
656, Offer in Compromise.
Section 1
Personal and Household Information
Last Name
First Name
Social Security Number
Date of Birth
(mm/dd/yyyy)
-
-
Marital status
Do you:
Home Physical Address
(Street, City, State, ZIP Code)
Unmarried
Own your home
Rent
Other
(specify e.g., share rent, live with relative, etc.)
Married
County of Residence
Primary Phone
Home Mailing Address
(if different from above or Post Office Box number)
(
)
-
Secondary Phone
Fax Number
(
)
-
(
)
-
Provide information about your spouse.
Spouse's Last Name
Spouse's First Name
Date of Birth
Social Security Number
(mm/dd/yyyy)
-
-
Provide information for all other persons in the household or claimed as a dependent.
Claimed as a dependent
Contributes to
Name
Age
Relationship
on your Form 1040?
household income?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Section 2
Employment Information for Wage Earners
Complete this section if you or your spouse are wage earners and received a Form W-2. If you or your spouse have self-employment income (that is
you file a Schedule C, E, F, etc.) instead of, or in addition to wage income, you must also complete Business Information in Sections 4, 5, and 6.
Your Employer’s Name
Employer’s Address
(street, city, state, zip code)
Do you have an ownership interest in this
If yes, check the business interest that
business?
applies:
Partner
Officer
Yes
No
Sole proprietor
Your Occupation
How long with this employer
(years)
(months)
Spouse’s Employer's Name
Employer’s Address
(street, city, state, zip code)
Does your spouse have an ownership
If yes, check the business interest that
interest in this business?
applies:
Partner
Officer
Yes
No
Sole proprietor
Spouse's Occupation
How long with this employer
(years)
(months)
433-A (OIC)
Form
(Rev. 3-2017)
Catalog Number 55896Q
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