Form 433-F - Collection Information Statement
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3Department of the Treasury – Internal Revenue Service
Form 433-F
Collection Information Statement
(Rev. 6-2012)
Full Name(s) and Address
Your Social Security Number or Individual Taxpayer Identification Number
Your Spouse’s Social Security Number or Individual Taxpayer Identification Number
Your Telephone Numbers
Spouse’s Telephone Numbers
If address provided above is different than last return filed please check here.
Home:
Home:
County of Residence
Work:
Work:
Cell:
Cell:
Enter the number of people in the household who can be claimed on this year’s tax return including you and your spouse.
under 65
65 and over
A. ACCOUNTS / LINES OF CREDIT (including Banking Institutions, Checking and Savings accounts, Credit Unions, Certificates of
Deposit, Individual Retirement Accounts (IRAs), Keogh Plans, Simplified Employee Pensions, 401(k) Plans, Profit Sharing Plans,
Mutual Fund, Stock Brokerage Accounts and Other Investments)
Name and Address of Institution
Account Number
Type of Account
Current Balance / Value
B. REAL ESTATE (home, vacation property, timeshares and other real estate, use additional sheets if necessary)
Monthly Payment(s)
Financing
Current Value
Balance Owed
Equity
Description/Location/County
Purchase Price
Year Purchased
Year Refinanced
Refinance Amount
Primary Residence
Other
Purchase Price
Year Purchased
Refinance Amount
Year Refinanced
Primary Residence
Other
Year Purchased
Purchase Price
Year Refinanced
Refinance Amount
Primary Residence
Other
C. OTHER ASSETS (cars, boats, recreational vehicles, whole life policies, etc.) Include Make and Model or Life Insurance company
in Description
Description
Monthly Payment
Year Purchased Final Payment (mo / yr)
Balance Owed
Equity
Current Value
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433-F
Catalog 62053J
TURN PAGE TO CONTINUE
Form
(Rev. 6-2012)
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