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. January 2014)
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, 2, 3, 7, 8, 9 and the signature line in Section 10.
Self-employed individuals Complete Sections 4, 5, 6, in addition to Sections 1, 2 (if applicable), 3, 7, 8, 9 and the signature line in Section 10.
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)
Marital status
Do you:
Home Address
(Street, City, State, ZIP Code)
Own your home
Rent
Unmarried
Other
(specify e.g., share rent, live with relative, etc.)
Married
County of Residence
Primary Phone
Mailing Address
(if different from above or Post Office Box number)
(
)
-
Fax Number
Secondary Phone
(
)
-
(
)
-
Provide information about your spouse.
Spouse's Last Name
Spouse's First Name
Date of Birth
Social Security Number
(mm/dd/yyyy)
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
Employment Information for Wage Earners
If you or your spouse have self-employment income (that is you file a Schedule C, E, F, etc.) instead of, or in addition to wage income, you
must complete Business Information in Sections 4, 5, and 6.
Your Employer’s Name
Employer’s Address
(street, city, state, zip code)
Do you have an interest in this business?
Yes
No
Your Occupation
How long with this employer
(years)
(months)
Employer’s Address
(street, city, state, zip code)
Spouse’s Employer's Name
Does your spouse have an interest in this business?
Yes
No
How long with this employer
Spouse's Occupation
(years)
(months)
433-A (OIC)
Catalog Number 55896Q
Form
(Rev. 1-2014)

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