The IRS 433-F form is a financial statement used by the Internal Revenue Service to assess a taxpayer's ability to pay their tax debts. This form collects information about your income, expenses, and assets. Completing it accurately is essential for negotiating payment plans or settling tax liabilities.
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Form 433-F
(February 2019)
Department of the Treasury - Internal Revenue Service
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:
County of Residence
Work:
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
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 Account
Current
Balance/Value
Check if
Business Account
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.)
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.)
Type of Virtual Currency
Name of Virtual Currency Wallet,
Exchange or Digital Currency
Exchange (DCE)
Email Address Used to Set-up
With the Virtual Currency
Exchange or DCE
Location(s) of Virtual Currency (Mobile Wallet, Online, and/or External Hardware storage)
Virtual Currency
Amount and Value in US dollars as of today (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
Primary Residence
Other
Year Refinanced
Refinance Amount
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
/
D. CREDIT CARDS (Visa, MasterCard, American Express, Department Stores, etc.)
Type
Credit Limit
Minimum Monthly Payment
TURN PAGE TO CONTINUE
Catalog Number 62053J
www.irs.gov
Form 433-F (Rev. 2-2019)
Page 2 of 4
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. Include virtual currency wallet, exchange or digital currency exchange.
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
(Visa, Master Card, etc.)
Issuing Bank Name and Address
Merchant Account Number
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)
How often are you paid (check one)
Weekly
Biweekly
Semi-monthly
Monthly
Gross per pay period
Taxes per pay period (Fed)
(State)
(Local)
How long at current employer
Spouse’s current Employer (name and address)
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
Child Support Income
Net Self Employment Income
Net Rental Income
Unemployment Income
Pension Income
Interest/Dividends Income
Social Security Income
Other:
H. MONTHLY NECESSARY LIVING EXPENSES List monthly amounts. (For expenses paid other than monthly, see instructions.)
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
Health Insurance
Expenses
only.
Out of Pocket Health Care
Food
Total
Housekeeping Supplies
Clothing and Clothing Services
5. Other
Personal Care Products & Services
Miscellaneous
Child / Dependent Care
Estimated Tax Payments
2. Transportation
Term Life Insurance
Retirement (Employer Required)
Gas / Insurance / Licenses /
Retirement (Voluntary)
Parking / Maintenance etc.
Union Dues
Public Transportation
Delinquent State & Local Taxes
(minimum payment)
3. Housing & Utilities
Student Loans (minimum
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)
Maintenance and Repairs
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
Page 3 of 4
Instructions for Form 433-F, Collection Information Statement
What is the purpose of Form 433F?
Form 433-F is used to obtain current financial information necessary for determining how a wage earner or self-employed individual can satisfy an outstanding tax liability.
Note: You may be able to establish an Online Payment Agreement on the IRS web site. To apply online, go to https://www.irs.gov, click on “I need to pay my taxes,” and select “Installment Agreement” under the heading “What if I can't pay now?”
If you are requesting an Installment Agreement, you should submit Form 9465, Installment Agreement Request, along with Form 433-F. (A large down payment may streamline the installment agreement process, pay your balance faster and reduce the amount of penalties and interest.
Please retain a copy of your completed form and supporting documentation. After we review your completed form, we may contact you for additional information. For example, we may ask you to send supporting documentation of your current income or substantiation of your stated expenditures.
If any section on this form is too small for the information you need to supply, please use a separate sheet.
Section A – Accounts / Lines of Credit
List all accounts, even if they currently have no balance. However, do not enter bank loans in this section. Include business accounts, if applicable. If you are entering information for a stock or bond, etc. and a question does not apply, enter N/A.
Section B – Real Estate
List all real estate you own or are purchasing including your home. Include insurance and taxes if they are included in your monthly payment. The county/description is needed if different than the address and county you listed above. To determine equity, subtract the amount owed for each piece of real estate from its current market value.
Section C – Other Assets
List all cars, boats and recreational vehicles with their make, model and year. If a vehicle is leased, write “lease” in the “year purchased” column. List whole life insurance policies with the name of the insurance company. List other assets with a description such as “paintings”, “coin collection”, or “antiques”. If applicable, include business assets, such as tools, equipment, inventory, and intangible assets such as domain names, patents, copyrights, etc. To determine equity, subtract the amount owed from its current market value. If you are entering information for an asset and a question does not apply, enter N/A.
Section D – Credit Cards
List all credit cards and lines of credit, even if there is no balance owed.
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.
E1: List all Accounts Receivable owed to you or your business. Include federal, state and local grants and contracts.
E2: Complete if you or your business accepts credit card payments (e.g., Visa, MasterCard, etc.) and/or virtual currency wallet, exchange or digital currency exchange.
Section F – Employment Information
Complete this section if you or your spouse are wage earners.
If attaching a copy of current pay stub, you do not need to complete this section.
Section G – Non-Wage Household Income
List all non-wage income received monthly.
Net Self-Employment Income is the amount you or your
spouse earns after you pay ordinary and necessary monthly business expenses. This figure should relate to the yearly net profit from Schedule C on your Form 1040 or your current year profit and loss statement. Please attach a copy of Schedule C or your current year profit and loss statement. If net income is a loss, enter “0”.
Net Rental Income is the amount you earn after you pay ordinary and necessary monthly rental expenses. This figure should relate to the amount reported on Schedule E of your Form 1040.
Do not include depreciation expenses. Depreciation is a non-cash expense. Only cash expenses are used to determine ability to pay).
If net rental income is a loss, enter “0”.
Other Income includes distributions from partnerships and subchapter S corporations reported on Schedule K-1, and from limited liability companies reported on Form 1040, Schedule C, D or E. It also includes agricultural subsidies, gambling income, oil credits, and rent subsidies. Enter total distributions from IRAs if not included under Pension Income.
Section H – Monthly Necessary Living Expenses
Enter monthly amounts for expenses. For any expenses not paid monthly, convert as follows:
If a bill is paid …
Calculate the monthly
amount by …
Quarterly
Dividing by 3
Multiplying by 4.3
Biweekly (every two
Multiplying by 2.17
weeks)
Semimonthly (twice
Multiplying by 2
each month)
Page 4 of 4
For expenses claimed in boxes 1 and 4, you should provide the IRS allowable standards, or the actual amount you pay if the amount exceeds the IRS allowable standards. IRS allowable standards can be found by accessing https://www.irs.gov/ businesses/small-businesses-self-employed/collection-financial- standards.
Substantiation may be required for any expenses over the standard once the financial analysis is completed.
The amount claimed for Miscellaneous cannot exceed the standard amount for the number of people in your family. The miscellaneous allowance is for expenses incurred that are not included in any other allowable living expense items. Examples are credit card payments, bank fees and charges, reading material and school supplies.
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. Documentation may include pay statements, bank and investment statements, loan statements and bills for recurring expenses, etc.
Housing and Utilities – Includes expenses for your primary residence. You should only list amounts for utilities, taxes and insurance that are not included in your mortgage or rent payments.
Rent – Do not enter mortgage payment here. Mortgage payment is listed in Section B.
Transportation – Include the total of maintenance, repairs, insurance, fuel, registrations, licenses, inspections, parking, and tolls for one month.
Public Transportation – Include the total you spend for 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.
Child / Dependent Care – Enter the monthly amount you pay for the care of dependents that can be claimed on your Form 1040.
Estimated Tax Payments – Calculate the monthly
amount you pay for estimated taxes by dividing the quarterly amount due on your Form 1040ES by 3.
Life Insurance – Enter the amount you pay for term life insurance only. Whole life insurance has cash value and should be listed in Section C.
Delinquent State & Local Taxes – Enter the minimum
amount you are required to pay monthly. Be prepared to provide a copy of the statement showing the amount you owe and if applicable, any agreement you have for monthly payments.
Student Loans – Minimum payments on student loans for the taxpayer’s post-secondary education may be 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.
The IRS 433-F form is a crucial document for individuals seeking to resolve their tax liabilities with the Internal Revenue Service. However, several other forms and documents often accompany it to provide a comprehensive view of one's financial situation. Below is a list of these additional documents, each serving a specific purpose in the tax resolution process.
Gathering these forms and documents is essential for a smooth process when dealing with the IRS. By having everything prepared, individuals can present a complete financial picture, facilitating discussions and negotiations regarding their tax obligations.