Fillable Form 433-F - Collection Information Statement (Page 3 of 3) in pdf

Instructions

If you can establish an agreement to pay using the Online

Section G – Monthly Necessary Living Expenses

Payment Agreement on the IRS web site, you do not need to fill

Enter monthly amounts for expenses. For any expenses not paid

out this form. To access the Online Payment Agreement, go to

monthly, calculate the monthly amount as follows:

, click on “I Need To>>” and select “Set Up a

• If paid quarterly - divide by three.

Payment Agreement” to start.

• If paid weekly - multiply by 4.3.

• If paid biweekly - multiply by 2.17.

If any section is too small for the information you need to supply,

For expenses claimed in boxes 1 and 4 you may provide actual

please use a separate sheet.

expenses or the IRS allowable standards. IRS allowable standards can

After we review your completed form we may contact you for

be found by accessing

and entering “Collection

additional information. For example, we may ask you to send

Financial Standards” in the search field. Substantiation may be required

supporting documentation of your current income or

for any expenses over the standard once the financial analysis is

substantiation of your stated expenditures.

completed. The amount claimed for Miscellaneous cannot exceed the

standard amount for the number of people in your family. The

Section A – Accounts / Lines of Credit

miscellaneous allowance is for expenses incurred that are not included

List all accounts, even if they currently have no balance. However,

in any other allowable living expense items. Examples are credit card

do not enter bank loans in this section.

payments, bank fees and charges, reading material and school

Section B – Real Estate

supplies. If you do not have access to the IRS web site, itemize your

actual expenses and we will ask you for additional proof, if required.

List all real estate you own or are purchasing including your home.

Documentation may include pay statements, bank and investment

Include insurance and taxes in the monthly payment. The county/

statements, loan statements and bills for recurring expenses, etc.

description is needed if different than the address and county you

listed above. To determine equity, subtract the amount owed for

If you do not have access to the IRS website, itemize your actual

expenses and we will ask you for additional proof, if required.

each piece of real estate from its current market value.

Rent - Do not enter mortgage payment here. Mortgage payment is

Section C – Other Assets

listed in Section B.

List all cars, boats, and recreational vehicles with their make,

Medical - Enter only ongoing medical expenses.

model, and year. If a vehicle is leased, write “lease” in the “year

Out-of-Pocket health care expenses include:

purchased” column. List whole life insurance policies with the

• Medical services

name of the insurance company. List other assets with a

• Prescription drugs

description such as “paintings”, “coin collection”, or “antiques”.

• Medical supplies, including eyeglasses and contact lenses.

To determine equity, subtract the amount owed from its current

Child / Dependent Care - Enter the monthly amount you pay for the

market value.

care of dependents that can be claimed on your Form 1040.

Section D – Credit Cards

Estimated Tax Payments - Calculate the monthly amount you pay for

List all credit cards and lines of credit, even if there is no balance

estimated taxes by dividing the quarterly amount due on your Form

owed.

1040ES by 3.

Section E – Wage Information

Life Insurance - Enter the amount you pay for term life insurance only.

Whole life insurance has cash value and should be listed in Section C.

Provide the name and address of employers for you and your

Delinquent State & Local Taxes - Enter the minimum amount you

spouse. Include both spouses’ income, even if the tax liability is

are required to pay monthly. Be prepared to provide a copy of the

not the result of a jointly filed return. Check the appropriate box

statement showing the amount you owe and if applicable, any

indicating how you are paid. List employment information for a

agreement you have for monthly payments.

second or part time on a separate sheet of paper.

Student Loans - Minimum payments on student loans for the

Section F – Non-Wage Household Income

taxpayer’s post-secondary education may be allowed if they are

Enter monthly amounts for all sources of household income. For

guaranteed by the federal government. Be prepared to provide proof

any income not received monthly, calculate the monthly amount

of loan balance and payments.

as follows:

Court Ordered Payments. For any court ordered payments be

• If received quarterly - divide by three.

prepared to submit a copy of the court order portion showing the

amount you are ordered to pay, the signatures, and proof you are

• If received weekly - multiply by 4.3.

making the payments. Acceptable forms of proof are copies of

• If received biweekly - multiply by 2.17.

cancelled checks or copies of bank or pay statements.

Net Self-Employment Income is the amount you earn after you

pay ordinary and necessary monthly business expenses. This

figure should relate to the yearly net profit from Schedule C on

your Form 1040 or your current year profit and loss statement.

Please attach a copy of your current year profit and loss

statement. If net income is a loss, enter “0”.

Net Rental Income is the amount you earn after you pay

ordinary and necessary monthly rental expenses. This figure

should relate to the amount reported on Schedule E of your

Form 1040 (do not include depreciation expenses). If net rental

income is loss, enter “0”.

Other Income may include distributions from an IRA or reported

on a K-1, agricultural subsidies, oil credits, gambling income, etc.

Catalog 62053J

433-F

Form

(Rev. 6-2012)

Form 433-F - Collection Information Statement Page 3

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