Form 433-A (Oic) - Collection Information Statement For Wage Earners And Self-Employed Individuals

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Department of the Treasury — Internal Revenue Service
433-A (OIC)
Form
Collection Information Statement for Wage Earners and
(Rev. May 2012)
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
Individual Income Tax Return
partnership liability
An individual with a personal liability for Excise Tax
An individual who is self-employed or has self-employment
income. You are considered to be self-employed if you are in
An individual responsible for a Trust Fund Recovery Penalty
business for yourself, or carry on a trade or business.
Wage earners Complete sections 1, 3, 4 (Box 1), 6, and 7 including signature line on page 7.
Self-employed individuals Complete all sections and signature line on page 7
Note: Include attachments if additional space is needed to respond completely to any question.
Section 1
Personal and Household Information
Last Name
First Name
Date of Birth
Social Security Number
(mm/dd/yyyy)
Do you:
Marital status
Home Address
(Street, City, State, ZIP Code)
Own your home
Rent
Married
Other
Unmarried
(specify e.g., share rent, live with relative, etc.)
County of Residence
Primary Phone
Mailing Address
(if different from above or Post Office Box number)
(
)
-
Secondary Phone
Fax Number
(
)
(
)
-
-
Employer's Name
Employer's Address
(Street, City, State, ZIP Code)
Occupation
How Long?
Provide information about your spouse.
Spouse's Last Name
First Name
Social Security Number
Date of Birth
(mm/dd/yyyy)
Occupation
Employer's Address
(Street, City, State, ZIP Code)
Employer's Name
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
Self-employed Information
If you or your spouse is self-employed, complete this section.
Is your business a sole proprietorship
?
(filing Schedule C)
Address of Business
(If other than personal residence)
Yes
No
Name of Business
Business Telephone Number
Employer Identification Number Business Website
Trade Name or dba
(
)
-
Average Gross Monthly
Description of Business
Total Number of Employees
Frequency of Tax Deposits
Payroll $
433-A (OIC)
Catalog Number 55896Q
Form
(Rev. 5-2012)

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