Editable IRS Form 433-A Fillable Template

Form 433-A Collection Information Statement for Wage Earners and Self-Employed Individuals February 2019 Department of the Treasury Internal Revenue Service Wage Earners Complete Sections 1 2 3 4 and 5 including the signature line on page 4. Section 6 Business Information Is the business a sole proprietorship filing Schedule C Yes Continue with Sections 6 and 7. No Complete Form 433-B. All other business entities including limited liability companies partnerships or corporations must complete Form 433-B. Taxpayer s Signature Spouse s signature Date After we review the completed Form 433-A you may be asked to provide verification for the assets encumbrances income and expenses reported. Documentation may include previously filed income tax returns pay statements self-employment records bank and investment statements loan statements bills or statements for recurring expenses etc. IRS USE ONLY Notes Sections 6 and 7 must be completed only if you are SELF-EMPLOYED. S for 6 months or longer If yes answer the following Dates lived abroad from mmddyyyy To mmddyyyy 9a Are you the beneficiary of a trust estate or life insurance policy If yes answer the following Place where recorded EIN Anticipated amount to be received When will the amount be received Name of the trust estate or policy 9b Are you a trustee fiduciary or contributor of a trust Do you have a safe deposit box business or personal If yes answer the following Value Location Name address and box number s Contents Value at Time of Transfer Date Transferred mmddyyyy List Asset s To Whom or Where was it Transferred Catalog Number 20312N www.irs.gov Form 433-A Rev. 2-2019 Page CASH ON HAND Include cash that is not in a bank Total Cash on Hand PERSONAL BANK ACCOUNTS Include all checking online and mobile e.g. PayPal accounts money market accounts savings accounts and stored value cards e.g. payroll cards government benefit cards etc.. No Complete Form 433-B. All other business entities including limited liability companies partnerships or corporations must complete Form 433-B. Business Name Address if different than 1b Business Website web address Total Number of Employees Frequency of Tax Deposits Does the business engage in e-Commerce Internet sales If yes complete lines 61a and 61b Type of Business Federal Contractor Average Gross Monthly Payroll PAYMENT PROCESSOR e.g. PayPal Authorize. Answer all questions or write N/A if the question is not applicable. Self-Employed Individuals Complete Sections 1 3 4 5 6 and 7 and the signature line on page 4. Answer all questions or write N/A if the question is not applicable. For Additional Information refer to Publication 1854 How To Prepare a Collection Information Statement. Include attachments if additional space is needed to respond completely to any question* SSN or ITIN on IRS Account Name on Internal Revenue Service IRS Account Employer Identification Number EIN Section 1 Personal Information 1a Full Name of Taxpayer and Spouse if applicable 1b Address Street City State ZIP code County of Residence 1c Home Phone 1e Business Phone 1d Cell Phone 1f Business Cell Phone 2b Name Age and Relationship of dependent s 2a Marital Status Married Unmarried Single Divorced Widowed SSN or ITIN Date of Birth mmddyyyy Driver s License Number and State 3a Taxpayer 3b Spouse Section 2 Employment Information for Wage Earners If you or your spouse have self-employment income instead of or in addition to wage income complete Business Information in Sections 6 and 7.