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Department of the Treasury - Internal Revenue Service
Form 433-H Installment Agreement Request and
(May 2019)
Collection Information Statement
Use Form 433-H if you earn wages, you are requesting an installment agreement, and your liability is either greater than $50,000 or cannot be paid
within 72 months.
Tip If you can pay your liability within 72 months or less and owe $50,000 or less, you may be able to establish an installment agreement online, even if
you have not yet received a bill for your taxes. Go to IRS.gov to apply to pay online.
Caution Don't file this form if you can pay your balance in full within 120 days. Instead, call the number on your most recent notice. If you are in
bankruptcy or we have accepted your offer-in-compromise, see Bankruptcy or Offer-in-Compromise, in the instructions.
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
Part 1 - INSTALLMENT AGREEMENT REQUEST Complete to request an installment agreement
1. Enter the total amount you owe as shown on your tax return(s) (or notices(s)) Form Tax Period
2. If you have additional balances due that are not reflected on Line 1, list the total here (even if they are included in an existing
installment agreement) Form Tax Period(s)
3. Add lines 1 & 2 and enter the result
4. Enter the amount of any payment you are making with this request (See instructions.)
5. Subtract line 4 from line 3 and enter the result
6. Enter the amount you can pay each month. Make your payments as large as possible to limit interest and penalty charges,
since these charges will continue to accrue until you pay in full. (If you have an existing installment agreement, this amount should
represent your total proposed monthly payment amount for all your liabilities.) If no payment amount is listed on line 6, a payment will
be determined for you by analyzing the information you provided on your financial statement.
7. Enter the date you want to make your payment each month. Do not enter a date later than the 28th
8. If you want to make your payments by direct debit from your checking account, see the instructions and fill in lines 8a and 8b. This is the most
convenient way to make your payments and it will ensure that they are made on time.
a. Routing number
b. Account number

I authorize the U.S. Treasury and its designated Financial Agent to initiate a monthly ACH debit (electronic withdrawal) entry to the financial institution
account indicated for payments of my federal taxes owed, and the financial institution to debit the entry to this account. This authorization is to
remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke payment, I must contact the U.
S. Treasury Financial Agent at 1-800-829-1040 no later than 14 business days prior to the payment (settlement) date. I also authorize the financial
institutions involved in the processing of the electronic payments of taxes to receive confidential information necessary to answer inquiries and
resolve issues related to the payments.

c. If you are unable to make electronic payments through a debit instrument (debit payments) by entering into a direct debit installment agreement
(DDIA) in Sections 8. a. and b. above, please check the box below:
I am unable to make debit payments.
Note: Not checking this box indicates that you are able but choosing not to make debit payments. See Instructions for line 8c. for details.
9. If you want to make your payments by payroll deduction, check this box and attach a completed Form 2159, Payroll Deduction Agreement
Part 2 - COLLECTION INFORMATION STATEMENT Complete Sections A through G below to provide financial information
A. ACCOUNTS / LINES OF CREDIT
PERSONAL BANK ACCOUNTS Include checking, online, mobile (e.g., PayPal), savings accounts, money market accounts. (Use additional sheets if
necessary.)
Name and Address of Institution Account Number Type of Current Check if
Account Balance/Value Business Account

Catalog Number 71232U www.irs.gov Form 433-H (5-2019)

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                                                                                                                                  Page 2
Part 2 - COLLECTION INFORMATION STATEMENT (Continued)
INVESTMENTS Include Certificates of Deposit, Trusts, Individual Retirement Accounts (IRAs), Keogh Plans, Simplified Employee Pensions, 401(k) 
Plans, Profit Sharing Plans, Mutual Funds, Stocks, Bonds, Commodities (Silver, Gold, etc.), 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 

VIRTUAL CURRENCY (CRYPTOCURRENCY) List all virtual currency you own or in which you have a financial interest (e.g., Bitcoin, Ethereum, 
Litecoin, Ripple, etc.). (Use additional sheets if necessary.)
                                                                                                                       Virtual Currency 
                         Name of Virtual Currency Wallet,  Email Address Used to Set-up  Location(s) of Virtual Currency  Amount and Value in 
Type of Virtual Currency Exchange or Digital Currency         With the Virtual Currency (Mobile Wallet, Online, and/or US dollars as of today 
                               Exchange (DCE)                 Exchange or DCE           External Hardware storage)     (e.g., 10 Bitcoins 
                                                                                                                       $64,600 USD)

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 
                                                  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. (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

Catalog Number 71232U                                         www.irs.gov                                              Form 433-H (5-2019)

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                                                                                                                                                  Page 3
Part 2 - COLLECTION INFORMATION STATEMENT (Continued)
E. 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 the lines regarding gross pay and taxes.)
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 

F. NON-WAGE HOUSEHOLD INCOME  List monthly amounts. 
Alimony Income                              Net Rental Income                                          Interest/Dividends Income
Child Support Income                        Unemployment Income                                        Social Security Income 
Net Self Employment Income                  Pension Income                                             Other
G. MONTHLY NECESSARY LIVING EXPENSES  List monthly amounts. (For expenses paid other than monthly, see instructions.)
1. Food / Personal Care See instructions. National Standards for food,           4. Medical See instructions. National Standards for out of pocket health 
clothing and other items apply nationwide. For expenses claimed in box           case expenses. For expenses claimed in box 4, you should provide the 
1, you should provide the IRS allowable standards (found by accessing            IRS allowable standards (found by accessing IRS.gov and entering 
IRS.gov and entering "Collection Financial Standards" in the search box) or your "Collection Financial Standards" in the search box) or your actual expenses. If 
actual expenses. If you claim a higher amount for a specific expense,            you claim a higher amount for a specific expense, you must be able to 
you must be able to verify that amount.                                          verify that amount.

                                    Actual Monthly IRS Allowed                                                      Actual Monthly        IRS Allowed
                                    Expenses                                                                        Expenses
                           Food                                                                 Health Insurance
     Housekeeping Supplies                                                       Out of Pocket Health Care Expenses
Clothing and Clothing Services                                                                              Total
Personal Care Products & Services                                                5. Other                           Actual Monthly        IRS Allowed
                  Miscellaneous                                                                                     Expenses
                           Total                                                          Child / Dependent Care
                                                                                       Estimated Tax Payments
2. Transportation                   Actual Monthly IRS Allowed
                                    Expenses                                                Term Life Insurance
     Gas / Insurance / Licenses /                                                Retirement (Employer Required)
     Parking / Maintenance etc.                                                             Retirement (Voluntary)
       Public Transportation                                                                          Union Dues
                           Total                                                 Delinquent State & Local Taxes 
                                                                                                (minimum payment)
3. Housing & Utilities              Actual Monthly IRS Allowed
                                    Expenses
                                                                                 Student Loans (minimum payment)
                           Rent
Electric, Oil/Gas, Water/Trash                                                   Court Ordered Child Support
Telephone/Cell/Cable/Internet                                                             Court Ordered Alimony
Real Estate Taxes and Insurance                                                  Other Court Ordered Payments
       (if not included in B above)                                              Other (specify)
     Maintenance and Repairs                                                     Other (specify)
                           Total                                                                            Total
Notes

Under penalty of perjury, I declare to the best of my knowledge and belief this request for installment agreement, statement of assets, liabilities and 
income, and all other information is true, correct and complete.
Your Signature                                                          Spouse’s Signature                                                Date

Catalog Number 71232U                                                   www.irs.gov                                                  Form 433-H (5-2019)

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                                                                                                                Page 4
                      Instructions for Form 433-H, Installment Agreement Request  
                                  and Collection Information Statement
What is the purpose of Form 433-H?                         supporting documentation of your current income or 
Form 433-H, Installment Agreement Request and              substantiation of your stated expenditures.
Collection Information Statement, is used by wage earners 
                                                           Instructions
to provide current financial information and request an 
installment agreement, allowing the Service to determine   Part 1 – Installment Agreement Request
how best to satisfy outstanding tax liabilities. 
                                                           We will usually let you know within 30 days after we 
However, before requesting an installment agreement,       receive your request whether it is approved or denied. 
you should consider other payment options, which           However, if this request is for tax due on a return you filed 
may be less costly, such as getting a bank loan or         after March 31, it may take us longer than 30 days to 
using available credit on a credit card.                   reply. 
You must submit all required returns that have not been    We will review the financial information provided in 
filed. Your request for an installment agreement will be   Sections A through G, determine your ability to pay and 
denied if all required tax returns have not been filed.    compare it with the monthly payment amount you 
Use Form 433-H if you earn wages and are requesting an     proposed in Part 1, Line 6. We will contact you if we have 
installment agreement and either:                          questions or believe you can pay your liability more 
•  You cannot pay your outstanding liability within 72     quickly. 
    months, or                                             If we approve your request, we will send you a notice 
•  Your outstanding liability exceeds $50,000.             detailing the terms of your agreement and requesting a 
                                                           fee of $225 ($107 if you make your payments by direct 
Do not use Form 433-H if:
                                                           debit). 
•  Your outstanding liability is $50,000 or less and you 
    can pay within 72 months. Instead, use Form 9465,      Low income taxpayer. You are a low income taxpayer if 
    Installment Agreement Request. See the tip below.      your adjusted gross income, as determined for the most 
•  You are self-employed. Instead, use Form 433-D,         recent year for which such information is available, is at or 
    Installment Agreement.                                 below 250% of the federal poverty rate. However, you 
                                                           may qualify to pay a reduced fee of $43 if your income is  
•  You operate a business. Instead, use Form 433-D, 
                                                           below a certain level. The IRS will let you know whether 
    Installment Agreement.
                                                           you have low income taxpayer status. 
    If you can pay your outstanding liability within 120 
TIP                                                        If the IRS does not say you qualify for low income 
    days, there is no user fee for this type of 
    agreement, and you may be able to establish an         taxpayer status, you can request reconsideration by using 
    Online Payment Agreement (OPA). To apply online,       Form 13844, Application For Reduced User Fee For 
    go to http://www irs.gov, and enter “Online Payment    Installment Agreements.  The user fee for low income 
    Agreement" in the "Search" box.                        taxpayers is $43, which may be waived or reimbursed if 
    If you owe $50,000 or less in combined tax,            certain conditions are met. See the instructions for line 8c. 
TIP                                                        for details.  
    penalties and interest and filed all required returns, 
    you may be able to establish an installment            You will also be charged interest and may be charged a 
    agreement online. Go to IRS.gov to pay online. You     late payment penalty on any tax not paid by its due date, 
    may owe a lower user fee if you establish your         even if your request to pay in installments is granted. 
    agreement through the OPA application.                 Interest and any applicable penalties will be charged until 
A large down payment to reduce your liability to $50,000   the balance is paid in full. To limit interest and penalty 
or less may streamline the installment agreement process,  charges, file your return on time and pay as much of the 
pay your balance faster and reduce the amount of           tax as possible with your return (or notice). 
penalties and interest charged.                            By approving your request, we agree to let you pay the tax 
Bankruptcy or offer-in-compromise. If you are in           you owe in monthly installments instead of immediately 
bankruptcy or we have accepted your offer-in-              paying the amount in full. In return, you agree to make 
compromise, do not file this form. Instead, call           your monthly payments on time. 
1-800-829-1040 to get the number of your local IRS         You also agree to meet all your future tax obligations. This 
Insolvency function for bankruptcy or Technical Support    means that you must have enough withholding or 
function for offer-incompromise.                           estimated tax payments so that your tax obligation for 
Please retain a copy of your completed form and            future years is paid in full when you timely file your return.
supporting documentation. After we review your 
completed form, we may contact you for additional 
information. For example, we may ask you to send

Catalog Number 71232U                                    www.irs.gov                            Form 433-H (5-2019)

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Part 1 – Installment Agreement Request Notice of Federal Tax Lien. A Notice of Federal Tax Lien
(Continued) (NFTL) may be filed to protect the government’s interests
until you pay in full. If you meet certain criteria, you may
Any refund you are due in a future year will be applied be able to get the NFTL withdrawn. To learn more about
against the amount you owe. If your refund is applied to NFTL withdrawals and to see if you qualify, visit www.irs.
your balance, you are still required to make your regular gov and enter "lien" in the “Search” box.
monthly installment payment.
Payment methods. You can make your payments by Where To File
check, money order, credit card, or one of the other Send Form 433-H, Installment Agreement Request and
payment methods shown next. The fee for setting up an Collection Information Statement, with any attachments,
installment agreement for each payment method is also to the Internal Revenue Service Center at the address in
shown. the table below that applies to you.
THEN use this
Payment Method Applicable User Fee IF you live in . . .
address . . .
Check, money order, credit card Alaska, Arizona, Colorado, Internal Revenue Service
or payroll deduction installment $225 Connecticut, Delaware, District PO Box 9041
agreement of Columbia, Hawaii, Idaho, CSCO Bal Due
llinois, Maine, Maryland, Andover, MA
Direct debit installment
$107 Massachusetts, Montana, New 01810-9041
agreement
Hampshire, New Jersey, New
Your specific tax situation will determine which payment Mexico, Nevada,
options are available to you. You may owe a lower user North Dakota, Oregon, Rhode
fee if you establish your agreement through the OPA Island, South Dakota,
application on the IRS web site; however, not all taxpayers Tennessee, Utah, Vermont,
qualify to apply for an installment agreement online to pay Washington,
off their balance over time. Go to IRS.gov, and enter Wisconsin, Wyoming
“Online Payment Agreement” in the “Search” box for more Alabama, Florida, Georgia, Internal Revenue Service
information. Kentucky, Louisiana, PO Box 47421, Stop 74
After we receive each payment, we will send you a notice Mississippi, North Carolina, Doraville, GA 30362
showing the remaining amount you owe, and the due date South Carolina, Texas, Virginia
and amount of your next payment. But if you choose to Arkansas, California, Iowa, Internal Revenue Service
have your payments automatically withdrawn from your Indiana, Kansas, Michigan, Stop P-4 5000
checking account, you will not receive a notice. Your bank Minnesota, Missouri, PO Box 219236
statement is your record of payment. Nebraska, New York, Ohio, Kansas City, MO
We will also send you an annual statement showing the Oklahoma, Pennsylvania, 64121-9236
amount you owed at the beginning of the year, all West Virginia
payments made during the year, and the amount you owe A foreign country, American Internal Revenue Service
at the end of the year.If you do not make your payments Samoa, or Puerto Rico (or are CSCO Stop 4-N31.142
on time or do not pay any balance due on a return you file excluding income under 2970 Market St.
later, you will be in default on your agreement and we may Internal Philadelphia, PA 19104
take enforcement actions, such as the filing of a Notice of Revenue Code section 933),
Federal Tax Lien or initiating an IRS levy action, to collect Guam, the U.S. Virgin Islands,
the entire amount you owe. or use an APO or FPO
For additional information on the IRS collection process, address, or
see Pub. 594, The IRS Collection Process, or Pub. 1, file Form 2555, 2555-EZ, or
Know Your Rights as a Taxpayer. You may also visit IRS. 4563, or are a dual-status alien
gov and put “collection process” into the "Search" box. To For all taxpayers who are bona fide residents of Guam,
ensure that your payments are made timely, you should the U.S. Virgin Islands, or the Commonwealth of the
consider making them by direct debit. See the instructions Northern Mariana Islands, See Pub. 570, Tax Guide for
for lines 8a and 8b on page 5. Income From U.S. Possessions.
An installment agreement may be terminated if
▲! you provide materially incomplete or inaccurate
CAUTION
information in response to an IRS request for a
financial update.

Catalog Number 71232U www.irs.gov Form 433-H (5-2019)

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Part 1 – Installment Agreement Request applies to you. See the instructions for line 4 for details on
(Continued) what to write on your payment.

Line 1 Line 8a, 8b, and 8c
Enter the tax form, tax period, and the total amount you Making your payments by direct debit will help
TIP
owe as shown on your tax return(s) (or notice(s)). ensure that your payments are made timely and
that you are not in default of this agreement.
Line 2 To pay by direct debit from your checking account at a
List additional tax forms, tax periods, and balances due bank or other financial institution (such as a mutual fund,
that are not reflected on Line 1 (even if they are included brokerage firm, or credit union), fill in lines 8a and 8b.
in an existing installment agreement). Check with your financial institution to make sure that a
direct debit is allowed and to get the correct routing and
Line 3 account numbers.
Add lines 1 & 2 and enter the result.
Line 8a. The routing number must be nine digits. The
first two digits of the routing number must be 01 through
Line 4 12 or 21 through 32. Use a check to verify the routing
Enter the amount of any payment you are making with this number. On the following sample check, the routing
request. number is 250250025. But if your check is payable
Even if you cannot pay the full amount you owe now, you through
should pay as much as possible to limit penalty and a financial institution different from the one at which you
interest charges. If you are filing this form with your tax have your checking account, do not use the routing
return, make the payment with your return. For details on number on that check. Instead, contact your financial
how to pay, see your tax return instructions. institution for the correct routing number.
Attach a check or money order payable to “United States Line 8b. The account number can be up to 17
Treasury.” Do not send cash. Be sure to include: characters (both numbers and letters). Include hyphens
but omit spaces and special symbols. Enter the number
• Your name, address, SSN/IT N, and daytime phone from left to right and leave any unused boxes blank. On
number. the following sample check, the account number is
• The tax year and tax return (for example, “2012 20202086. Do not include the check number.
Form 1040”) for which you are making this request. We may file a Notice of Federal Tax Lien (NFTL)
▲! against you, or may have previously filed one. If
CAUTION
Line 5 you meet certain criteria, you may be able to get
Subtract line 4 from line 3 and enter the result. the NFTL withdrawn. To learn more about NFTL
withdrawals and to see if you qualify, visit IRS gov
Line 6 and enter "lien" in the “Search” box.
Enter the amount you can pay each month. Make your
payments as large as possible to limit interest and penalty If you qualify as a low income taxpayer, you will receive a
charges. The charges will continue until you pay in full. (If waiver of the installment agreement user fees if you agree
you have an existing installment agreement, this amount to make electronic payments through a debit instrument
should represent your total proposed monthly payment (debit payments) by following the direct debit instructions
amount for all your liabilities.) in lines 8 a. and b.
If no payment amount is listed on line 6, a payment will be Line 8c. If you are a low income taxpayer that is unable to
determined for you by analyzing the information provided make debit payments, please indicate by checking the box
on your financial statement. in line 8c. to receive a reimbursement of the reduced user
fees upon completion of your agreement.
Line 7 If you do not check the box in line 8c. and you do not
You can choose the day of each month your payment is provide your checking account information in lines 8a. and
due. This can be on or after the 1st oft he month, but no b., then you will be treated as being able to but choosing
later than the 28th of the month. For example, if your rent not to make debit payments and your user fees will not be
or mortgage payment is due on the 1st of the month, you reimbursed upon completion of your installment
may want to make your installment payments on the 15th. agreement.
If we approve your request, we will tell you the month and
day that your first payment is due.
If we have not replied by the date you chose for your first
payment, you can send the first payment to the Internal
Revenue Service Center at the address shown earlier that
Catalog Number 71232U www.irs.gov Form 433-H (5-2019)

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Part 1 – Installment Agreement Request Section E – Employment Information
(Continued) Enter wage information for you or your spouse as
applicable. If attaching a copy of current pay stub(s), you
Sample Check - Lines 8a and 8b do not need to complete this section.
Roberta Maple
Paul Maple SAMPLE 1234▲ Section F – Non-Wage Household Income
123 Pear Lane 15-000000000
Anyplace, VA 20000
PAY TO THE List all non-wage income received monthly.
ORDER OF $
Routing Account Other Income includes distributions from partnerships and
Number Number DOLLARS subchapter S corporations reported on Schedule K-1, and
ANYPLACE BANK Line 8a Line 8b Do not inlude from limited liability companies reported on Form 1040,
Anyplace, VA 20000
For the check number. Schedule C, D or E. It also includes agricultural subsidies,
|:250250025| :202020"'86". 1234 ◀ gambling income, and oil credits. Enter total distributions
from RAs if not included under Pension Income.
The routing and account numbers may be in different places on your
check.
Section G – Monthly Necessary Living Expenses
Line 9 Enter monthly amounts for expenses. For any expenses
If you want to make your payments by payroll deduction, not paid monthly, convert as follows:
check the box on line 9 and attach a completed and
Calculate the
signed Form 2159, Payroll Deduction Agreement, with If a bill is paid
your request. Ask your employer to complete and sign monthly amount by
their portion of Form 2159, Payroll Deduction Agreement. Quarterly Dividing by 3
Weekly Multiplying by 4 3
Part 2 – Collection Information Statement
Biweekly (every two weeks) Multiplying by 2.17
Section A – Accounts/Lines of Credit
Semimonthly (twice each month) Multiplying by 2
List all accounts, even if they currently have no balance.
However, do not enter bank loans in this section. Include
National Standards for food, clothing and other items
business accounts, if applicable. If you are entering
apply nationwide. For expenses claimed in boxes 1 and 4
information for a stock or bond, etc. and a column box
you should provide the IRS allowable standards that can
does not apply, enter N/A.
be found by accessing IRS.gov and entering “Collection
Financial Standards” in the search box.
Section B – Real Estate
If you claim a higher amount for a specific expense, you
List all real estate you own or are purchasing including
must verify and substantiate that amount.
your home. Include insurance, taxes and homeowner's
association dues if they are included in your monthly The amount claimed for Miscellaneous cannot exceed the
payment. The county/description is needed if different standard amount for the number of people in your family.
than the address and county you listed above. To The miscellaneous allowance is for expenses incurred that
determine equity, subtract the amount owed for each are not included in any other allowable living expense
piece of real estate from its current market value. items. Examples are credit card payments, bank fees and
charges, reading material and school supplies.
Section C – Other Assets If you do not have access to the IRS web site, itemize
List all cars, boats and recreational vehicles with their your actual expenses and we will ask you for additional
make, model and year. If a vehicle is leased, write “lease” proof, if required. Documentation may include pay
in the “year purchased” column. List whole life insurance statements, bank and investment statements, loan
policies with the name of the insurance company. List statements and bills for recurring expenses, etc.
other assets with a description such as “paintings”, “coin Housing and Utilities – Includes expenses for your
collection”, or “antiques”. If applicable, include business primary residence. You should only list amounts for
assets, such as tools, equipment, inventory, and intangible utilities, taxes, insurance and homeowner's association
assets such as domain names, patents, copyrights, etc. dues that are not included in your mortgage or rent
To determine equity, subtract the amount owed from its payments.
current market value. If you are entering information for an
Rent – Do not enter mortgage payment here. Mortgage
asset and a column box does not apply, enter N/A.
payment is listed in Section B.

Section D – Credit Cards Transportation – Include the total of maintenance,
repairs, insurance, fuel, registrations, licenses,
List all credit cards and lines of credit, even if there is no
inspections, parking, and tolls for one month.
balance owed.
Catalog Number 71232U www.irs.gov Form 433-H (5-2019)

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Public Transportation – Include the total you spend for Privacy Act and Paperwork Reduction Act Notice.
public transportation if you do not own a vehicle or if you Our legal right to ask for the information on this form is
have public transportation costs in addition to vehicle sections 6001, 6011, 6012(a), 6109, and 6159 and their
expenses. regulations. We will use the information to process your
Medical – You are allowed expenses for health insurance request for an installment agreement. The reason we
and out-of-pocket health care costs. need your name and social security number is to secure
proper identification. We require this information to gain
Health insurance – Enter the monthly amount you pay for
access to the tax information in our files and properly
yourself or your family.
respond to your request. You are not required to request
Out-of-Pocket health care expenses – Are costs not an installment agreement. If you do request an installment
covered by health insurance, and include: agreement, you are required to provide the information
requested on this form. Failure to provide this information
• Medical services may prevent processing your request; providing false
• Prescription drugs information may subject you to fines or penalties.
• Dental expenses You are not required to provide the information requested
• Medical supplies, including eyeglasses and contact on a form that is subject to the Paperwork Reduction Act
lenses. Medical procedures of a purely cosmetic unless the form displays a valid OMB control number.
nature, such as plastic surgery or elective dental Books or records relating to a form or its instructions must
work are generally not allowed. be retained as long as their contents may become
material in the administration of any Internal Revenue law.
Child / Dependent Care – Enter the monthly amount Generally, tax returns and return information are
you pay for the care of dependents that can be claimed confidential, as required by section 6103. However, we
on your Form 1040. may give this information to the Department of Justice for
Estimated Tax Payments – Calculate the monthly civil and criminal litigation, and to cities, states, the District
amount you pay for estimated taxes by dividing the of Columbia, and U.S. commonwealths and possessions
quarterly amount due on your Form 1040ES by 3. to carry out their tax laws. We may also disclose this
information to other countries under a tax treaty, to federal
Life Insurance – Enter the amount you pay for term life
and state agencies to enforce federal nontax criminal
insurance only. Whole life insurance has cash value and
laws, or to federal law enforcement and intelligence
should be listed in Section C.
agencies to combat terrorism.
Delinquent State & Local Taxes – Enter the minimum
The average time and expenses required to complete and
amount you are required to pay monthly. Be prepared to
file this form will vary depending on individual
provide a copy of the statement showing the amount you
circumstances. For the estimated averages, see the
owe and if applicable, any agreement you have for
instructions for your income tax return.
monthly payments.
If you have suggestions for making this form simpler, we
Student Loans – Minimum payments on student loans
would be happy to hear from you. See the instructions for
for the taxpayer’s post-secondary education may be
your income tax return.
allowed if they are guaranteed by the federal
government. Be prepared to provide proof of loan
balance and payments.
Court Ordered Payments – For any court ordered
payments, be prepared to submit a copy of the court
order portion showing the amount you are ordered to
pay, the signatures, and proof you are making the
payments. Acceptable forms of proof are copies of
cancelled checks or copies of bank or pay statements.
Other Expenses (not listed above) – We may allow
other expenses in certain circumstances. For example, if
the expenses are necessary for the health and welfare of
the taxpayer or family, or for the production of income.
Specify the expense and list the minimum monthly
payment you are billed.
Signature(s) & Date - Review the terms of this
agreement and financial information entered. Please
sign and date this completed agreement form. Then,
return it to IRS at the address
shown on page 5.
Catalog Number 71232U www.irs.gov Form 433-H (5-2019)

PDF file checksum: 836168916

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