Collection Information Statement for Wage Earners and Self-Employed Individuals Revision Date 04/22/2022

• Legal Form Number: 433-A (OIC)
• Year: 2024
• Issuer: Treasury Department
• Section: Treasury Department

Catalog Number 55896Q www.irs.gov Form 433-A (OIC) (Rev. 4-2023)

Form 433-A (OIC)

(April 2023)

Department of the Treasury — Internal Revenue Service

Collection Information Statement for Wage Earners and

Self-Employed Individuals

Use this form if you are

● An individual who owes income tax on a Form 1040, U.S.

Individual Income Tax Return

● An individual with a personal liability for Excise Tax

● An individual responsible for a Trust Fund Recovery Penalty

● An individual who is self-employed or has self-employment

income. You are considered to be self-employed if you are in

business for yourself, or carry on a trade or business.

● An individual who is personally responsible for a partnership

liability (only if the partnership is submitting an offer)

● An individual who is submitting an offer on behalf of the

estate of a deceased person

Note: Include attachments if additional space is needed to respond completely to any question. This form should only be used with the Form

656, Offer in Compromise.

Section 1 Personal and Household Information

Last name First name Date of birth (mm/dd/yyyy) Social Security Number

- -

Marital status

Unmarried Married

If married, date of marriage (mm/dd/yyyy)

Home physical address (street, city, state, ZIP code) Do you

Own your home Rent

Other (specify e.g., share rent, live with relative, etc.)

If you were married and lived in AZ, CA, ID, LA, NM, NV, TX, WA or WI within the last ten years check here

County of residence Primary phone

( ) -

Secondary phone

( ) -

FAX number

( ) -

Home mailing address (if different from above or post office box number)

Provide information about your spouse.

Spouse's last name Spouse's first name Date of birth (mm/dd/yyyy)

Provide information for all other persons in the household or claimed as a dependent.

Name Age Relationship Claimed as a dependent

on your Form 1040 Contributes to

household income

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

Social Security Number

- -

Section 2 Employment Information for Wage Earners

Complete this section if you or your spouse are wage earners and receive a Form W-2. If you or your spouse have self-employment income (that is

you file a Schedule C, E, F, etc.) instead of, or in addition to wage income, you must also complete Business Information in Sections 4, 5, and 6.

Your employer’s name Pay period Weekly Bi-weekly

Monthly Other

Employer’s address (street, city, state, ZIP code)

Do you have an ownership interest in this business

Yes (also complete and submit Form 433-B)No

Your occupation How long with this employer

(years) (months)

Spouse’s employer's name Pay period Weekly Bi-weekly

Monthly Other

Employer’s address (street, city, state, ZIP code)

Does your spouse have an ownership interest in this business

Yes (also complete and submit Form 433-B)No

Spouse's occupation How long with this employer

(years) (months)