Collection Information Statement for Wage Earners and Self-Employed Individuals Revision Date 08/05/2022

• Issuer: Treasury Department
• Section: Treasury Department

Catalog Number 20312N www.irs.gov Form 433-A (Rev. 7-2022)

Form 433-A

(July 2022)

Department of the Treasury

Internal Revenue Service

Collection Information Statement for Wage

Earners and Self-Employed Individuals

Wage Earners Complete Sections 1, 2, 3, 4, and 5 including the signature line on page 4. 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.

Section 1: Personal Information

1a Full Name of Taxpayer and Spouse (if applicable)

1b Address (street, city, state, ZIP code and country)

1d Home Phone

( )

1e Cell Phone

( )

1f Work Phone

( )

2a Marital Status: Married

Unmarried (Single, Divorced, Widowed)

2b SSN or ITIN Date of Birth (mmddyyyy)

Taxpayer

Spouse

1c County of Residence

2c Provide information on all other persons in household or claimed as

dependents

Name Age Relationship

3a Do you or your spouse have any outside business interests? Include

any interest in an LLC, LLP, corporation, partnership, etc.

Yes (percentage of ownership %)

Title

No

3b Business name

3c Type of business (select one)

Partnership LLC

Corporation

Other

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.

Taxpayer

4a Taxpayer's Employer Name

4b Address (street, city, state, ZIP code and country)

4c Work Telephone Number

( )

4d

Does employer allow contact at work

Yes No

4e

How long with this employer

(years) (months)

4f Occupation

4g

Number claimed as a dependent

on your Form 1040

4h Pay Period:

Weekly

Monthly

Bi-weekly

Other

Spouse

5a Spouse's Employer Name

5b Address (street, city, state, ZIP code and country)

5c Work Telephone Number

( )

5d

Does employer allow contact at work

Yes No

5e

How long with this employer

(years) (months)

5f Occupation

5g

Number claimed as a dependent

on your Form 1040

5h Pay Period:

Weekly

Monthly

Bi-weekly

Other

Section 3: Other Financial Information (Attach copies of applicable documentation)

6 Are you a party to a lawsuit (If yes, answer the following) Yes No

Plaintiff Defendant

Location of Filing Represented by Docket/Case No.

Amount of Suit

$

Possible Completion Date (mmddyyyy)

Subject of Suit

7 Have you ever filed bankruptcy (If yes, answer the following) Yes No

Date Filed (mmddyyyy)

Date Dismissed (mmddyyyy) Date Discharged (mmddyyyy)

Petition No. Location Filed

8 In the past 10 years, have you lived outside of the U.S for 6 months or longer (If yes, answer the following) Yes No

Dates lived abroad: from (mmddyyyy) To (mmddyyyy)

9a Are you the beneficiary of a trust, estate, or life insurance policy including those located in foreign countries or

jurisdictions (If yes, answer the following)

Yes No

Place where recorded: EIN:

Name of the trust, estate, or policy

Anticipated amount to be received

$

When will the amount be received

9b Are you a trustee, fiduciary, or contributor of a trust Yes No

Name of the trust: EIN:

10 Do you have a safe deposit box (business or personal) including those located in foreign countries or jurisdictions

(If yes, answer the following)

Yes No

Location (Name, address and box number(s)) Contents Value

$

11 In the past 10 years, have you transferred any assets with a fair market value of more than $10,000 including real

property, for less than their full value (if yes, answer the following)

Yes No

List Asset(s) Value at Time of Transfer

$

Date Transferred (mmddyyyy)

To Whom or Where was it Transferred