Form 433-F - Collection Information Statement Page 2
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3D. CREDIT CARDS (Visa, MasterCard, American Express, Department Stores, etc.)
Type
Credit Limit
Balance Owed
Minimum Monthly Payment
E. WAGE INFORMATION (If you have more than one employer, include the information on another sheet of paper. If attaching a
copy of current pay stub, you do not need to complete this section.)
Your current Employer (name and address)
Spouse’s current Employer (name and address)
How often are you paid? (Check one)
How often are you paid? (Check one)
Weekly
Biweekly
Semi-monthly
Monthly
Weekly
Biweekly
Semi-monthly
Monthly
Gross per pay period
Gross per pay period
Taxes per pay period
Taxes per pay period
(Fed)
(State)
(Local)
(Fed)
(State)
(Local)
How long at current employer
How long at current employer
F. NON-WAGE HOUSEHOLD INCOME (List monthly amounts. For Self-Employment and Rental Income, list the monthly amount
received after expenses or taxes and attach a copy of your current year profit and loss statement.)
Alimony Income:
Net Rental Income:
Interest/Dividends Income:
Child Support Income:
Social Security Income:
Unemployment Income:
Net Self Employment Income:
Pension Income:
Other:
G. MONTHLY NECESSARY LIVING EXPENSES (List monthly amounts. For expenses paid other than monthly, see instructions.)
1. Food / Personal Care
3. Housing & Utilities
5. Other
Child / Dependent Care:
Estimated Tax Payments:
Food:
Rent:
Term Life Insurance:
Retirement (Employer Required):
Housekeeping Supplies:
Electric, Oil/Gas, Water/Trash:
Retirement (Voluntary):
Clothing and Clothing Services:
Telephone/Cell/Cable/Internet:
Union Dues:
Personal Care Products & Services:
Real Estate Taxes and Insurance:
Delinquent State & Local Taxes
(if not included in B above)
Miscellaneous:
(minimum payment):
Total:
Total:
Student Loans (minimum payment):
Court Ordered Child Support:
2. Transportation
4. Medical
Court Ordered Alimony:
Other Court Ordered Payments:
Health Insurance:
Gas/Insurance/Licenses/Parking/
Maintenance etc.:
Out of Pocket Health Care
Expenses:
Public Transportation:
Under penalty 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
433-F
Catalog 62053J
Form
(Rev. 6-2012)
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Parent category: Financial