Form 433-A Collection Information Statement Checklist
Overview and Purpose
Form 433-A is the Collection Information Statement for Wage Earners and Self-Employed Individuals. The IRS uses this form to gather detailed financial information from taxpayers unable to pay their tax liabilities in full.
The form provides a complete picture of your financial situation, including income, expenses, assets, and liabilities, enabling the IRS to determine appropriate payment arrangements or collection alternatives.
Who Must Complete This Form
Wage earners complete Sections 1, 2, 3, 4, and 5, plus the signature line on page 4.
Self-employed individuals complete Sections 1, 3, 4, 5, 6, and 7, as well as the signature line.
Those with both wage and self-employment income are required to complete all seven sections.
Answer all questions or write “N/A” if not applicable. Partnerships, corporations, and multi-member LLCs must use Form 433-B instead. Only sole proprietors filing Schedule C complete Sections 6 and 7 of Form 433-A.
Ten-Step Completion Guide
Step 1: Personal Identification Information
Provide your full legal name, spouse’s name if applicable, complete mailing address, county of residence, and contact numbers. Include Social Security Numbers or ITINs for both spouses, dates of birth, and a list of all household members with ages and relationships. Disclose any ownership interests in outside businesses with percentages, titles, and entity types.
Step 2: Employment Information
For wage earners, provide the employer name, address, and work phone number, and indicate whether your employer permits workplace contact. Document employment length, occupation, number of dependents claimed on Form 1040, and pay period frequency. If your spouse works, provide identical information for their employment.
Step 3: Other Financial Information
Disclose any lawsuits you are party to, including case details, amounts, and expected completion dates. Report bankruptcy filings with dates and petition numbers. Indicate if you lived outside the U.S. for six months or more in the past ten years. Disclose beneficiary interests in trusts, estates, or life insurance policies. Report safe deposit boxes, including their contents and values. List asset transfers exceeding $10,000 made in the past ten years for less than full value.
Step 4: Document All Personal Assets
Report cash on hand and all personal bank accounts, including checking, savings, online platforms like PayPal, money market accounts, and stored value cards. For each account, provide institution details, account numbers, and current balances.
List all investments, including stocks, bonds, mutual funds, retirement accounts, and commodities. Document digital assets such as Bitcoin, Ethereum, and NFTs with wallet information, storage locations, and current values. Identify individuals with access to private keys.
Report available credit from lines of credit and credit cards with limits, amounts owed, and available credit. Disclose life insurance policies with cash value, policy numbers, owners, and loan balances. Document all real property with descriptions, locations, purchase dates, fair market values, loan balances, monthly payments, and equity. Include lender contact information.
List all vehicles, boats, RVs, and motorcycles with year, make, model, mileage, VIN, current values, loan balances, and monthly payments. Report personal assets, including furniture, artwork, jewelry, collections, and intangible assets such as patents, copyrights, and domain names.
Step 5: Monthly Income and Expense Statement
Calculate gross monthly income from all sources. For wages, multiply weekly gross by 4.3, bi-weekly by 2.17, or semi-monthly by 2. Report wages, interest, dividends, business income, rental income, distributions, pensions, Social Security, child support, alimony, and other income, including sharing economy earnings from platforms like Uber, Airbnb, YouTube, and cryptocurrency sales.
Document monthly expenses, including food, clothing, housing, utilities, vehicle costs, public transportation, health insurance, out-of-pocket medical costs, court-ordered payments, child care, life insurance, current taxes, secured debts, and other necessary expenses. The IRS generally does not allow deductions for private school tuition, college expenses, charitable contributions, or voluntary retirement contributions unless they are proven essential for health, welfare, or income production.
Step 6: Business Information for Self-Employed
Confirm your business is a sole proprietorship filing Schedule C. Provide the business name, address, phone number, EIN, website, business type, and employee count. Indicate if you are a federal contractor and provide the average monthly payroll and tax deposit frequency.
If engaged in e-commerce, list all payment processors, including PayPal, cryptocurrency exchanges, and virtual wallets, along with their account numbers. List credit cards accepted with merchant account numbers and issuing banks.
Report business cash on hand and all business bank accounts with balances. Document accounts receivable, including government contracts, with status, due dates, and amounts due. List business assets, including tools, equipment, inventory, and intangible assets like licenses and patents, with values, loan balances, and equity.
Step 7: Sole Proprietorship Income and Expenses
Specify your accounting method (cash or accrual). Use a prior 3, 6, 9, or 12-month period to determine typical income and expenses.
Report monthly business income, including gross receipts, rental income, interest, dividends, and other sources. Document monthly expenses, including materials, inventory, wages, rent, supplies, utilities, vehicle costs, repairs, insurance, and current taxes.
Calculate net business income by subtracting expenses from income. Add back depreciation and depletion. Eliminate duplicate deductions, such as home office expenses. Enter net income on line 23 of Section 5. If the result is a loss, enter zero.
Step 8: Gather Supporting Documentation
Prepare to verify prior tax returns, pay statements, self-employment records, bank statements, investment statements, loan documents, and bills for recurring expenses. The IRS may request these after reviewing your form.
Step 9: Sign and Date the Certification
Both the taxpayer and their spouse must sign under penalty of perjury, certifying that all information is true, correct, and complete. For joint liabilities, both parties must sign.
If an authorized representative signs on your behalf, attach Form 2848, Power of Attorney and Declaration of Representative. Representatives with a valid POA may legally sign Form 433-A, though the IRS encourages personal signatures.
Step 10: Submit to the Assigned IRS Office
Submit your completed Form 433-A to the IRS representative or office handling your case. There is no standard mailing address because this form typically accompanies specific collection actions or applications. Follow the submission instructions from your assigned representative or any notice received.
Essential Rules and Considerations
Retain copies of the completed form and all supporting documentation. The IRS typically responds within thirty days. Answer all questions completely or mark “N/A.” Provide accurate financial information, as misrepresentation can result in penalties. Use current values and balances. Attach additional sheets if space is insufficient.
For questions requiring detailed explanations, reference Publication 1854, “How To Prepare a Collection Information Statement,” which provides comprehensive guidance on completing each section.
If only one spouse has a tax liability but both have income, list total household income and expenses if you share expenses or live in a community property state. If you do not live in a community property state and do not share expenses, list income and expenses for the liable taxpayer only.
Remain available to answer IRS questions and provide any additional documentation as needed during the review process. Prompt responses expedite resolution and demonstrate good faith cooperation in addressing your outstanding tax liability.
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This checklist is for educational purposes only and does not constitute tax or legal advice. Always review official IRS instructions and consult a qualified professional for guidance.
