Form               MD 433-A
(Rev. July 2022)
State of Maryland                                               Collection Information Statement for Individuals
                                                                                       (If you need additional space, please attach a separate sheet)
Comptroller of Maryland
Note:  Complete all blocks, except shaded areas.  Write “N/A” (not applicable) in those blocks that do not apply.
1 Taxpayer(s) name(s) and address                                       2  Phone number                                                                             3 Marital status

                                                                        4a       Taxpayer’s Social Security number                                                  4b Spouse’s Social Security number

County ______________________
Se o i t c         I   n                                                        Em          o l p yme               o f n I   t n rm       o i t a  n
5 Taxpayer’s employer or business                             a How long employed                 b Business phone number                                                     c Occupation
   (name and address)

                                                              d Number of exemptions              e Pay period:                            Weekly                Bi-weekly    f (Check appropriate box)
                                                                 claimed on W-4                                                                                  ________             Wage earner
                                                                                                                                           Monthly
                                                                                                     Payday: ___________ (Mon-Sun)                                                    Sole proprietor
                                                                                                                                                                                      Partner
6 Spouse’s employer or business                               a How long employed                 b Business phone number                                                     c Occupation
  (name and address)

                                                              d Number of exemptions              e Pay period:                            Weekly                Bi-weekly    f (Check appropriate box)
                                                                 claimed on W-4                                                                                  ________             Wage earner
                                                                                                                                           Monthly
                                                                                                  Payday: ___________ (Mon-Sun)                                                       Sole proprietor
                                                                                                                                                                                      Partner
Se o i t c         I I   n                                                      P s r e     on     o f n I   l a     rm           o i t a n
7 Name, address and telephone number of                                                           8 Other names or aliases                                                    9 Previous address(es)
   next of kin or other reference

10 Age and relationship of dependents living in your household (exclude yourself and spouse)

11 Date                                            a Taxpayer  b Spouse         12 Last filed income                                      a Number of exemptions                           b Adjusted gross income
  h t r i b   f o                                                                      a t  a t (   n r u t e r   x y   x e ) r a          i a l c  me  d

Se o i t c         I I I   n                                                    Gen           n i F   l a r e       an      o f n I   l a i c rm        o i t a n
13 Bank accounts (include savings and loans, credit unions, IRA and retirement plans, certificates of deposit, etc.)
   Nam             n I   f o   e o i t u t i t s n                      Ad       e r d s    s                                     Typ      A   f o   e ccou     t n   Accou      t n N . o                   B a l a nce

  Total (Enter in Item 21) ..................................................................................................................................................................................

Form MD 433-A       (Rev. 7-2022)                                                                                                                                                                     Page 2
Section III (continued)     General Financial Information
14 Charge cards and lines of credit from banks, credit unions, and savings and loans.
   Type of Account                    Name and Address of                                                             Monthly                                             Credit          Amount      Credit
   o   r C    r a d                             n i F an n i   l a i c o i t u t i t s n                              Payme                         t n                   i L m t i       Owed        Available

 Total (Enter in Item 27) ..........................................................................................
15 Safe deposit boxes rented or accessed         (List all locations, box numbers, and contents)

16 Real Property (Brief description and type of ownership)                                                                                                                Physical Address
a

                                                                                                                County _________________________________
b

                                                                                                                County _________________________________
c

                                                                                                                County _________________________________
17 Life Insurance (Name and Company)                     Policy Number                                                Type                                                Face Amount     Available Loan Value

                                                                                                                  Whole  Whole                        Term

                                                                                                                  Whole                               Term

                                                                                                                  Whole                               Term

                                                                                                                Total (Enter in Item 23)
18 Securities (stocks, bonds, mutual funds, money market funds, government securities, etc.):
   K n i d                  Qua   o   y t i t n r        Cu e r r            t n                                      Wh                      e r e                                            Own r e
                            Denom n i o i t a   n        V             u l a e                                        Loc                     e t a d                                       f o Record

19 Other information relating to your financial condition.  If you check the “Yes”                               box, please give dates and explain on page 4, Additional
    Information or Comments:

   a Court proceedings              Yes                    No                          b Bankruptcies                                                                                 Yes        No

   c Repossessions                  Yes                    No                          d Recent sale or other transfer of                                                             Yes        No
                                                                                         assets for less than full value
   e Anticipated increase                                                              f Participant or beneficiary
   n i   n i  come                  Yes                    No                            u r t   o t  e   , t s s   t i f o r p   , e t a t s h     n i r a . c t e   , g             Yes        No

Form MD 433-A                      (Rev. 7-2022)                                                                                                                     Page 3
Se   o i t c       V I   n                                                                      Ass  a   s t e n     a i L   d e i t i l i b s
                                                 Current     Current         Equity             Amount of              Name and Address of      Date               Date of
Des  o i t p i r c n                             M k r a t e Amount                      in      Monthly             Lien/Note Holder/Lender    Pledged             Final
                                                 Value       Owed            Ass            t e  Payme t n                                                         Payme  t n
20 Cash
21 Bank accounts (from item 13)
22 Securities (from item 18)
23 Cash or loan value of insurance
24 Vehicles leased or owned
     (model, year, license, tag #)
    a
    b
    c
25 Real property                   a
   (from Section III,
     item 16)                      b
                                   c
26 Other assets
    a
    b
    c
    d
    e
27 Bank revolving credit (from item 14)
28 Other liabilities               a
   (including bank
   loans, judgements               b
   notes, and
   charge accounts                 c
   not entered in
   item 13)                        d
                                   e
                                   f
                                   g
29 Federal taxes owed (prior years)
29 Totals                                                                  $                    $
                                                         Comptroller of Maryland Use Only Below This Line
                                                              Financial Verification/Analysis
                                                             Date Information or                       Date Property                          Estimated Forced
                           e t I m                       Encumb a r nc   e V e i f i r e d                     n I spe e t c d                S E   e l a q y t i u
Personal Residence
Other real property
Vehicles
Other personal property
State employment (husband and wife)
Income tax return
Wage statements (husband and wife)
Sources of income/credit (D&B report)
Expenses
Other assets/liabilities

Form MD 433-A               (Rev. 7-2022)                                                                                                      Page 4
Section V                  Monthly Income and Expense Analysis
          T n I   l a t o come                                                      Necess    n i v i L   y r a E   g xpenses
                                                                                                                             Comptroller’s use Only
Sou c r e                          Gross                                                      C i a l med                           A o l l wed
31 Wages/salaries (taxpayer)       $                    42 National Standard Expenses (1)     $                              $
32 Wages/salaries (spouse)                              43 Housing and utilities (2)
33  Interest, dividends                                 44 Transportation (3)
34 Net business income                                  45 Health care
     (from Form MD 433-B)
35 Rental income                                        46 Taxes (income and FICA)
36 Pension (taxpayer)                                   47 Court ordered payments
37 Pension (spouse)                                     48 Child/dependent care
38 Child support                                        49 Life insurance
39 Alimony                                              50 Secured or legally-perfected
                                                             debts (specify)
40 Other income                                         51 Other expenses (specify)

41 Total income                    $                    52T  E   l axpteonses                 $                              $

                                                        53 (Comptroller’s use only) Net       $
                                                             difference (income less necessary
                                                             living expenses)

                Certification    Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of
                                          assets, liabilities, and other information is true, correct, and complete.
54 Your signature                                       55 Spouse’s signature (if joint return filed)                        56 Date

Notes
1 Clothing and clothing services, food, housekeeping supplies, personal care products and services, and miscellaneous.
2 Rent or mortgage payment for the taxpayer’s principal residence.  Add the average monthly payment for the following expenses if they are     not
  included in the rent or mortgage payment: property taxes, homeowner’s or renter’s insurance, parking, necessary maintenance and repair,
  homeowner dues, condominium fees and utilities.  Utilities include gas, electricity, water, fuel oil, coal, bottled gas, trash and garbage collection,
  wood and other fuels, septic cleaning, and  telephone.
3 Lease or purchase payments, insurance, registration fees, normal maintenance, fuel, public transportation, parking, and tolls.
Additional information or comments:

                                          Comptroller of Maryland Use Only Below This Line
Explain any difference between Item 53 and the installment payment amount:

Name of Originator                                                                                                    Date