Department of the Treasury - Internal Revenue Service
Form 433-F 
(January 2017)
                                        Collection Information Statement
Name(s) and Address                                                Your Social Security Number or Individual Taxpayer Identification Number

                                                                   Your Spouse’s Social Security Number or Individual Taxpayer Identification Number

    If address provided above is different than last return filed, Your Telephone Numbers                 Spouse’s Telephone Numbers
    please check here                                              Home:                                  Home:
County of Residence                                                Work:                                  Work:
                                                                   Cell:                                  Cell:

Enter the number of people in the household who can be claimed on this year’s tax return including you and your spouse.  Under 65 65 and Over
If you or your spouse are self employed or have self employment income, provide the following information:
         Name of Business               Business EIN                     Type of Business                 Number of Employees (not counting owner)

A. ACCOUNTS / LINES OF CREDIT  Include checking, online, mobile (e.g., PayPal) and savings accounts, Certificates of Deposit, 
Trusts, Individual  Retirement Accounts (IRAs), Keogh Plans, Simplified Employee Pensions, 401(k) Plans, Profit Sharing Plans, Mutual 
Funds, Stocks, Bonds and other investments. If applicable, include business accounts. (Use additional sheets if necessary.)
                    Name and Address of Institution                      Account Number   Type of              Current            Check if  
                                                                                          Account         Balance/Value           Business Account 

B. REAL ESTATE  Include home, vacation property, timeshares, vacant land and other real estate. (Use additional sheets if necessary.)
Description/Location/County    Monthly Payment(s)                        Financing         Current Value       Balance Owed         Equity 
                                                    Year Purchased       Purchase Price 

                                                    Year Refinanced  Refinance Amount 
Primary Residence       Other 
                                                    Year Purchased       Purchase Price 

                                                    Year Refinanced  Refinance Amount 
Primary Residence       Other 
C. OTHER ASSETS  Include cars, boats, recreational vehicles, whole life policies, etc. Include make, model and year of vehicles  
and name of Life Insurance company in Description. If applicable, include business assets such as tools, equipment, inventory, etc. 
(Use additional sheets if necessary.)
            Description              Monthly Payment  Year Purchased Final Payment (mo/yr) Current Value       Balance Owed         Equity 
                                                                                   / 
                                                                                   / 
                                                                                   / 
                                                                                   / 
                                                                                   / 
                                                                                   / 
D. CREDIT CARDS  (Visa, MasterCard, American Express, Department Stores, etc.)
                        Type                                       Credit Limit           Balance Owed         Minimum Monthly Payment

                                                      TURN PAGE TO CONTINUE
Catalog Number 62053J                                              www.irs.gov                                 Form 433-F (Rev. 1-2017)

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E. BUSINESS INFORMATION  Complete E1 for Accounts Receivable owed to you or your business. (Use additional sheets if necessary.) 
Complete E2 if you or your business accepts credit card payments.
E1.  Accounts Receivable owed to you or your business
                     Name                                                                  Address                                            Amount Owed

                                                                                           List total amount owed from additional sheets
                                                                Total amount of accounts receivable available to pay to IRS now
E2. Name of individual or business on account

                   Credit Card                                          Issuing Bank Name and Address                                   Merchant Account Number
                   (Visa, Master Card, etc.)

F. EMPLOYMENT 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 (Fed)                       (State)        (Local)                    Taxes per pay period (Fed)          (State)         (Local) 
How long at current employer                                                               How long at current employer 
G. 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                         Unemployment Income                                     Social Security Income 
Net Self Employment Income                                              Pension Income                            Other: 
H. MONTHLY NECESSARY LIVING EXPENSES  List monthly amounts. (For expenses paid other than monthly, see instructions.)
National Standards 1. Food / Personal Care See instructions. If you do not spend more than 4. Medical                          Actual Monthly  IRS Allowed
the standard allowable amount for your family size, fill in the Total amount                                                   Expenses
                                                                                                          Health Insurance
only.                                            Actual Monthly IRS Allowed                      Out of Pocket Health Care 
                                                 Expenses
                                           Food                                                                 Expenses
                   Housekeeping Supplies                                                                              Total
Clothing and Clothing Services                                                             5. Other                            Actual Monthly  IRS Allowed
Personal Care Products & Services                                                                                              Expenses
                   Miscellaneous                                                                    Child / Dependent Care
                                           Total                                                 Estimated Tax Payments
                                                                                                      Term Life Insurance
2. Transportation                                Actual Monthly IRS Allowed
                                                 Expenses                                  Retirement (Employer Required)
                   Gas / Insurance / Licenses /                                                     Retirement (Voluntary)
                   Parking / Maintenance etc.                                                                   Union Dues
                   Public Transportation                                                   Delinquent State & Local Taxes 
                                           Total                                                      (minimum payment)
3. Housing & Utilities                           Actual Monthly IRS Allowed                      Student Loans (minimum 
                                                 Expenses                                                       payment)
                                           Rent                                            Court Ordered Child Support
    Electric, Oil/Gas, Water/Trash                                                                  Court Ordered Alimony
Telephone/Cell/Cable/Internet                                                              Other Court Ordered Payments
Real Estate Taxes and Insurance                                                            Other (specify)
                   (if not included in B above)                                            Other (specify)
                   Maintenance and Repairs                                                 Other (specify)
                                           Total                                                                      Total
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

Catalog Number 62053J                                                   www.irs.gov                                                     Form 433-F (Rev. 1-2017)

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      Instructions for Form 433-F, Collection Information Statement
What is the purpose of Form 433F?                                      E1: List all Accounts Receivable owed to you or your business. 
                                                                           Include federal, state and local grants and contracts.
Form 433-F is used to obtain current financial information 
necessary for determining how a wage earner or self-employed           E2: Complete if you or your business accepts credit card 
individual can satisfy an outstanding tax liability.                       payments (e.g., Visa, MasterCard, etc.).
Note: You may be able to establish an Online Payment 
Agreement on the IRS web site. To apply online, go to                  Section F – Employment Information
https://www.irs.gov, click on “I need to pay my taxes,” and select     Complete this section if you or your spouse are wage earners. 
“Installment Agreement” under the heading “What if I can't pay 
now?”                                                                  If attaching a copy of current pay stub, you do not need to 
                                                                       complete this section.
If you are requesting an Installment Agreement, you should 
submit Form 9465, Installment Agreement Request, along with            Section G – Non-Wage Household Income
Form 433-F. (A large down payment may streamline the 
installment agreement process, pay your balance faster and             List all non-wage income received monthly.  
reduce the amount of penalties and interest. 
                                                                       Net Self-Employment Income is the amount you or your 
Please retain a copy of your completed form and supporting             spouse earns after you pay ordinary and necessary monthly 
documentation. After we review your completed form, we may             business expenses. This figure should relate to the yearly net 
contact you for additional information. For example, we may ask        profit from Schedule C on your Form 1040 or your current year 
you to send supporting documentation of your current income or         profit and loss statement. Please attach a copy of Schedule C or 
substantiation of your stated expenditures.                            your current year profit and loss statement. If net income is a loss, 
                                                                       enter “0”.
If any section on this form is too small for the information 
you need to supply, please use a separate sheet.                       Net Rental Income is the amount you earn after you pay 
                                                                       ordinary and necessary monthly rental expenses. This figure 
Section A – Accounts / Lines of Credit                                 should relate to the amount reported on Schedule E of your Form 
List all accounts, even if they currently have no balance.             1040. 
However, do not enter bank loans in this section. Include 
                                                                       Do not include depreciation expenses. Depreciation is a non-cash 
business accounts, if applicable. If you are entering information 
                                                                       expense. Only cash expenses are used to determine ability to 
for a stock or bond, etc. and a question does not apply, enter N/A.
                                                                       pay). 
Section B – Real Estate                                                If net rental income is a loss, enter “0”. 
List all real estate you own or are purchasing including your 
home. Include insurance and taxes if they are included in your         Other Income includes distributions from partnerships and 
monthly payment. The county/description is needed if different         subchapter S corporations reported on Schedule K-1, and from 
than the address and county you listed above. To determine             limited liability companies reported on Form 1040, Schedule C, D 
equity, subtract the amount owed for each piece of real estate         or E. It also includes agricultural subsidies, gambling income, oil 
from its current market value.                                         credits, and rent subsidies. Enter total distributions from IRAs if 
                                                                       not included under Pension Income.
Section C – Other Assets
                                                                       Section H – Monthly Necessary Living 
List all cars, boats and recreational vehicles with their make, 
                                                                       Expenses
model and year. If a vehicle is leased, write “lease” in the “year 
purchased” column. List whole life insurance policies with the         Enter monthly amounts for expenses. For any expenses not paid 
name of the insurance company. List other assets with a                monthly, convert as follows:
description such as “paintings”, “coin collection”, or “antiques”. If 
applicable, include business assets, such as tools, equipment,                                     Calculate the monthly  
inventory, and intangible assets such as domain names, patents,           If a bill is paid … 
                                                                                                   amount by … 
copyrights, etc. To determine equity, subtract the amount owed 
from its current market value. If you are entering information for        Quarterly                Dividing by 3 
an asset and a question does not apply, enter N/A.
                                                                          Weekly                   Multiplying by 4.3 

Section D – Credit Cards                                                  Biweekly (every two      Multiplying by 2.17 
                                                                          weeks) 
List all credit cards and lines of credit, even if there is no balance 
owed.                                                                     Semimonthly (twice       Multiplying by 2 
                                                                          each month) 
Section E – Business Information
Complete this section if you or your spouse are self-employed, or 
have self-employment income. This includes self-employment 
income from online sales.
Catalog Number 62053J                                         www.irs.gov                                         Form 433-F (Rev. 1-2017)

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For expenses claimed in boxes 1 and 4, you should provide the       Child / Dependent Care –Enter the monthly amount you 
IRS allowable standards, or the actual amount you pay if the        pay for the care of dependents that can be claimed on your Form 
amount exceeds the IRS allowable standards. IRS allowable           1040. 
standards can be found by accessing https://www.irs.gov/
businesses/small-businesses-self-employed/collection-financial-     Estimated Tax Payments – Calculate the monthly  
standards.                                                          amount you pay for estimated taxes by dividing the quarterly 
                                                                    amount due on your Form 1040ES by 3. 
Substantiation may be required for any expenses over the 
standard once the financial analysis is completed.                                      Enter the amount you pay for term life 
                                                                    Life Insurance – 
The amount claimed for Miscellaneous cannot exceed the              insurance only. Whole life insurance has cash value and should 
standard amount for the number of people in your family. The        be listed in Section C. 
miscellaneous allowance is for expenses incurred that are not 
included in any other allowable living expense items. Examples      Delinquent State & Local Taxes –Enter the minimum 
are credit card payments, bank fees and charges, reading            amount you are required to pay monthly. Be prepared to provide 
material and school supplies.                                       a copy of the statement showing the amount you owe and if 
                                                                    applicable, any agreement you have for monthly payments. 
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.     Student Loans – Minimum payments on student loans for 
Documentation may include pay statements, bank and investment       the taxpayer’s post-secondary education may be allowed if they 
statements, loan statements and bills for recurring expenses, etc.  are guaranteed by the federal government. Be prepared to 
                                                                    provide proof of loan balance and payments. 
Housing and Utilities – Includes expenses for your primary 
residence. You should only list amounts for utilities, taxes and    Court Ordered Payments – For any court ordered  
insurance that are not included in your mortgage or rent            payments, be prepared to submit a copy of the court order portion 
payments.                                                           showing the amount you are ordered to pay, the signatures, and 
                                                                    proof you are making the payments. Acceptable forms of proof 
Rent – Do not enter mortgage payment here. Mortgage                 are copies of cancelled checks or copies of bank or pay 
payment is listed in Section B.                                     statements. 

Transportation – Include the total of maintenance, repairs,         Other Expenses not listed above – We may allow  
insurance, fuel, registrations, licenses, inspections, parking, and other expenses in certain circumstances. For example, if the 
tolls for one month.                                                expenses are necessary for the health and welfare of the 
                                                                    taxpayer or family, or for the production of income. Specify the 
Public Transportation – Include the total you spend for             expense and list the minimum monthly payment you are billed. 
public transportation if you do not own a vehicle or if you have 
public transportation costs in addition to vehicle expenses. 

Medical – You are allowed expenses for health  insurance and 
out-of-pocket health care costs.

Health insurance – Enter the monthly amount you pay for 
yourself or your family. 

Out-of-Pocket health care expenses – are costs not 
covered by health insurance, and include: 
•  Medical services
•  Prescription drugs
•  Dental expenses
•  Medical supplies, including eyeglasses and contact 
      lenses. Medical procedures of a purely cosmetic nature, 
      such as plastic surgery or elective dental work are 
      generally not allowed. 

Catalog Number 62053J                                        www.irs.gov                                  Form 433-F (Rev. 1-2017)