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How to prepare a

Collection Information Statement (Form 433-A)

Who should use Form 433-A? Items 17, 18 and 19 – Real Estate, Vehicles and Personal
Form 433-A is used to obtain current financial information Current Fair Market Value – Indicate the amount you could sell the
necessary for determining how a wage earner or self-employed asset for today.
individual can satisfy an outstanding tax liability. Date of Final Payment – Enter the date the loan or lease will be
fully paid.
You may need to complete Form 433-A:
• If you are an individual who owes income tax on Form 1040, Item 17 – Real Estate
List locations of all property that you own or are purchasing under
• If you are an individual who may be a responsible person for a contract. List lender or contract holder.
Trust Fund Recovery Penalty,
Item 18 – Personal Vehicles
• If you are an individual who may be personally responsible for a
partnership liability, List all vehicles owned and leased (cars, boats, RVs, etc.). If you
are leasing, list lessor. If you are purchasing, list lender.
• If you are an individual owner of a limited liability company that
is a disregarded entity, or Item 19 – Personal Assets
List other personal assets you own such as artwork, jewelry,
• If you are an individual who is self-employed or has self- antiques, furniture, collections (coins, guns, etc.). Include
employment income. You are self-employed if you are in intangible assets such as licenses, domain names, patents,
business for yourself, or carry on a trade or business as a sole copyrights, mining claims, etc.
proprietor or an independent contractor.
If you are a wage earner: Section 5 Monthly Income/Expenses
Complete Sections 1, 2, 3, 4 and 5, including the signature line on page 4. (See page 2 for additional information on income/expenses.) If
you are self-employed or have self-employment income, complete
If you are a self-employed individual:
Sections 6 and 7 before completing Section 5.
Complete Sections 1, 3, 4, 5, 6 and 7, and the signature line on page 4.
If only one spouse has a tax liability, but both have income, list the
If you are a wage earner and have self-employment income: total household income and expenses if you share expenses or live
Complete Sections 1 through 7, and the signature line on page 4. in a community property state. If you do not live in a community
property state and do not share expenses, list income and expenses
Answer all questions in these sections or write N/A if the question is
for the liable taxpayer only. Verification of expenses may be requested.
not applicable. Include attachments if additional space is needed to
respond completely to any question. You may be asked to provide Section 6 (Self-Employed only) Business Information/Assets
additional verification after we review the completed Form 433-A.
Item 61 – Payment Processor
Certification for Signature Line on page 4
List all third-party processors you use for business to accept credit
This requires the taxpayer’s signature. For joint income tax card payments. Include virtual currency wallet, exchange or digital
liabilities, both husband and wife must sign the statement. currency exchange.
Section 4 Personal Asset information (Foreign and Domestic) Item 64 – Business Bank Accounts
Items 13 – Personal Bank Accounts Enter all business bank accounts (checking, savings, online, mobile
(e.g., PayPal), money market, etc.); even if there is currently no
Enter all accounts (checking, savings, online, mobile (e.g., PayPal),
balance. Include stored value cards such as a telephone card or
money market, etc.); even if there is currently no balance. Include
prepaid debit card for expenses. Do not enter bank loans.
stored value cards such as a payroll card from an employer,
an electronic benefit card from a government agency or a child Item 66 – Business Assets
support payment card. Do not enter bank loans. List all other assets used in trade or business that were not
Item 14 – Investments included in previous sections.

List all investments such as stocks, bonds, mutual funds, virtual Section 7 (Self-Employed only) Business Income and
currency (e.g., Bitcoin, Ethereum, Ripple and Litecoin) etc. Include
Expenses
any interest you have in a business.
Complete Business Income and Expenses in Section 7 before completing
Item 15 – Available Credit
Monthly Income/Expense Statement in Section 5. The business information
Enter lines of credit and credit cards issued by a bank, credit in Section 7 should reconcile with your business profit and loss statement.
union, or savings and loan. Securing a credit card advance to pay See footnote 6 on page 6 of Form 433-A if using Form 1040, Schedule C.
taxes is an option to consider, but is not required.

Publication 1854 (Rev. 4-2024) Catalog Number 21563Q Department of the Treasury Internal Revenue Service www.irs.gov

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TOTAL INCOME Item 46 – Secured Debts
Items 20 and 21 – Wages Enter your average monthly payments for any other secured debts.
Enter your gross monthly wages and/or salaries. Do not deduct Do not duplicate mortgage or car payments entered in Items 36 or
withholding or allotments taken out of your pay such as insurance, union 37 above.
dues, car payments, etc. List these deductions in Total Living Expenses. Item 48 – Other Expenses
Item 23 – Net Business Income In certain circumstances, IRS may allow minimum payments on
Enter your monthly net business income from line 89 on page 6. other expenses, such as student loans, unsecured debts, tuition
or contributions if required for employment, etc. Attach a list and
Item 25 – Distributions explanation.
Enter the monthly average of your distributions from Partnerships,
Total Monthly National Standards for Food, Clothing and Misc.
Subchapter S Corporations or Limited Liability Companies. Enter 401K
(Section 5, item 35)
distributions if not included in Pension Income on lines 26 or 27.
Effective 04/22/2024
TOTAL LIVING EXPENSES (necessary)
To be necessary, expenses must provide for the health and welfare Expense One Two Three Four
of you and your family and/or provide for the production of Person Persons Persons Persons
income, and must be reasonable in amount. We may ask you to Food $458 $820 $977 $1,143
provide substantiation of certain expenses. Housekeeping supplies $44 $75 $83 $82
Item 35 – Standard for Food, Clothing and Misc. Apparel & services $87 $157 $187 $300
Enter the total amount for this item from the chart in the next
Personal care products $48 $80 $87 $97
column. If you claim a higher amount for a specific expense, you & services
must verify and substantiate that amount. The miscellaneous
Miscellaneous
allowance is for expenses that are not included in any other $171 $279 $343 $405
allowable living expense items (e.g., credit card payments, bank Total $808 $1,411 $1,677 $2,027
fees, school supplies, etc.).
More than four persons Over Four Persons Amount
Item 36 – Housing and Utilities For each additional person, add to $386
Enter the monthly rent or mortgage payment for your principal four-person total allowance:
residence. Add the average monthly payment for the following
To calculate the allowance, please read across to the column that
expenses, if they are not included in your rent or mortgage
matches the number of persons in your family.
payments: property taxes, homeowner’s or renter’s insurance,
necessary maintenance and repair, homeowner dues, When you have more than four persons in your family, you need to
condominium fees and utilities. multiply the amount of additional persons over four by the dollar
amount in the “Over Four” column; then add the answer to the
Item 37 – Vehicle Ownership Costs
dollar amount in the “Four” column. For example, when you have
Enter your monthly lease, purchase or loan payments. six persons in your family, you would multiply $386 by the two
Item 38 – Vehicle Operating Costs members of your family over four to get $772. You then would add
Enter the average monthly costs for insurance, licenses, this $772 to the $2,027 allowed for a family of four. As a result,
registration fees, inspections, normal repairs and maintenance, your allowed expenses would equal $2,799 ($772 + $2,027).
fuel, parking and tolls.
Total Monthly National Standards for Out-of-Pocket
Item 39 – Public Transportation Health Care Costs (Section 5, item 41)
Enter the average monthly public transportation expenses you pay
for bus, train and taxi fares, and any other mass transit fares. Effective 04/22/2024
Item 40 – Health Insurance Out-of-Pocket Health Care Costs
Enter your monthly expense for health insurance. Under 65 $83
65 and Older $158
Item 41– Out-of-Pocket Health Care Costs
Enter the amount for this item from the chart in the next column. To calculate the allowance, determine the number and age of
These are health care costs not covered by insurance. If you claim persons in your household and multiply by the amount reflected in
a higher amount, you must verify and substantiate the expenses. the chart.
Item 42 – Court Ordered Payments For example, a family of three persons, all under 65, would be
Include child support, alimony, etc. allowed $249 ($83 x 3).
Item 45 – Current Year Taxes NOTE: IRS will allow reasonable expenses that exceed the
Include state and Federal taxes withheld from salary or wages, standards if using the standards is not adequate to provide for
or paid as estimated taxes. If applicable, include county, city, and your necessary living expenses. You may be asked to provide
municipal income taxes. verification of expenses claimed.

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