Form 433-A (Oic) - Collection Information Statement For Wage Earners And Self-Employed Individuals Page 3

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Page 3 of 7
Section 3
Personal Asset Information
(Continued)
Cash value of life insurance policies
Name of Insurance Company
Policy Number
Current Cash Value
Less Loan Balance
= (4a) $
$
– $
Total of life insurance policies from attachment.
Less Any Loan Balance(s)
$
– $
= (4b) $
Add lines (4a) through (4b) = (4)
$
Real Estate (Enter information about any house, condo, co-op, time share, etc. that you own or are buying)
Property Address
(Street Address, City, State, ZIP Code)
Primary Residence
Yes
No
Date Purchased
County and Country
How is property titled?
?
Description of Property
(joint tenancy, etc.)
puo
Current Market Value
Less Loan Balance
(Mortgages, etc.)
$
X .8 = $
– $
Total Value of Real Estate = (5a) $
Primary Residence
Yes
No
Property Address
(Street Address, City, State, ZIP Code)
Date Purchased
County and Country
How is property titled?
?
Description of Property
(joint tenancy, etc.)
Current Market Value
Less Loan Balance
(Mortgages, etc.)
$
X .8 = $
– $
Total Value of Real Estate = (5b) $
Property Address
Primary Residence
Yes
No
(Street Address, City, State, ZIP Code)
Date Purchased
County and Country
How is property titled?
?
Description of Property
(joint tenancy, etc.)
Current Market Value
Less Loan Balance
(Mortgages, etc.)
$
X .8 = $
– $
Total Value of Real Estate = (5c) $
Total value of property(s) from attachment [current market value X .8 less any loan balance(s)]
(5d) $
Add lines (5a) through (5d) = (5)
$
Vehicles
(Enter information about any cars, boats, motorcycles, etc. that you own or lease)
Vehicle Make & Model
Year
Date Purchased
Mileage
Monthly Lease/Loan
Lease
Amount $
Loan
Current Market Value
Less Loan Balance
Total value of vehicle
(if the vehicle
$
X .8 = $
– $
= (6a) $
is leased, enter 0 as the total value)
Vehicle Make & Model
Year
Date Purchased
Mileage
Monthly Lease/Loan
Lease
Amount $
Loan
Current Market Value
Less Loan Balance
Total value of vehicle
(if the vehicle
$
X .8 = $
– $
= (6b) $
is leased, enter 0 as the total value)
Vehicle Make & Model
Year
Date Purchased
Mileage
Monthly Lease/Loan
Lease
Amount $
Loan
Current Market Value
Less Loan Balance
Total value of vehicle
(if the vehicle
$
X .8 = $
– $
= (6c) $
is leased, enter 0 as the total value)
433-A (OIC)
Catalog Number 55896Q
Form
(Rev. 5-2012)

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