How to Prepare a Collection Information Statement (Form 433-A) Revision Date 04/22/2022

• Legal Form Number: 433-A
• Year: 2022
• Issuer: Treasury Department
• Section: Treasury Department

How to prepare a

Collection Information Statement (Form 433-A)

Who should use Form 433-A?

Form 433-A is used to obtain current financial information

necessary for determining how a wage earner or self-employed

individual can satisfy an outstanding tax liability.

You may need to complete Form 433-A:

• If you are an individual who owes income tax on Form 1040,

• If you are an individual who may be a responsible person for a

Trust Fund Recovery Penalty,

• If you are an individual who may be personally responsible for a

partnership liability,

• If you are an individual owner of a limited liability company that

is a disregarded entity, or

• If you are an individual who is self-employed or has self-

employment income. You are self-employed if you are in

business for yourself, or carry on a trade or business as a sole

proprietor or an independent contractor.

If you are a wage earner:

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

If you are a self-employed individual:

Complete Sections 1, 3, 4, 5, 6 and 7, and the signature line on page 4.

If you are a wage earner and have self-employment income:

Complete Sections 1 through 7, and the signature line on page 4.

Answer all questions in these sections or write N/A if the question is

not applicable. Include attachments if additional space is needed to

respond completely to any question. You may be asked to provide

additional verification after we review the completed Form 433-A.

Certification for Signature Line on page 4

This requires the taxpayer’s signature. For joint income tax

liabilities, both husband and wife must sign the statement.

Section 4 Personal Asset information (Foreign and Domestic)

Items 13 – Personal Bank Accounts

Enter all accounts (checking, savings, online, mobile (e.g., PayPal),

money market, etc.); even if there is currently no balance. Include

stored value cards such as a payroll card from an employer,

an electronic benefit card from a government agency or a child

support payment card. Do not enter bank loans.

Item 14 – Investments

List all investments such as stocks, bonds, mutual funds, virtual

currency (e.g., Bitcoin, Ethereum, Ripple and Litecoin) etc. Include

any interest you have in a business.

Item 15 – Available Credit

Enter lines of credit and credit cards issued by a bank, credit

union, or savings and loan. Securing a credit card advance to pay

taxes is an option to consider, but is not required.

Items 17, 18 and 19 – Real Estate, Vehicles and Personal

Current Fair Market Value – Indicate the amount you could sell the

asset for today.

Date of Final Payment – Enter the date the loan or lease will be

fully paid.

Item 17 – Real Estate

List locations of all property that you own or are purchasing under

contract. List lender or contract holder.

Item 18 – Personal Vehicles

List all vehicles owned and leased (cars, boats, RVs, etc.). If you

are leasing, list lessor. If you are purchasing, list lender.

Item 19 – Personal Assets

List other personal assets you own such as artwork, jewelry,

antiques, furniture, collections (coins, guns, etc.). Include

intangible assets such as licenses, domain names, patents,

copyrights, mining claims, etc.

Section 5 Monthly Income/Expenses

(See page 2 for additional information on income/expenses.) If

you are self-employed or have self-employment income, complete

Sections 6 and 7 before completing Section 5.

If only one spouse has a tax liability, but both have income, list the

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. Verification of expenses may be requested.

Section 6 (Self-Employed only) Business Information/Assets

Item 61 – Payment Processor

List all third-party processors you use for business to accept credit

card payments. Include virtual currency wallet, exchange or digital

currency exchange.

Item 64 – Business Bank Accounts

Enter all business bank accounts (checking, savings, online, mobile

(e.g., PayPal), money market, etc.); even if there is currently no

balance. Include stored value cards such as a telephone card or

prepaid debit card for expenses. Do not enter bank loans.

Item 66 – Business Assets

List all other assets used in trade or business that were not

included in previous sections.

Section 7 (Self-Employed only) Business Income and

Expenses

Complete Business Income and Expenses in Section 7 before completing

Monthly Income/Expense Statement in Section 5. The business information

in Section 7 should reconcile with your business profit and loss statement.

See footnote 6 on page 6 of Form 433-A if using Form 1040, Schedule C.

Publication 1854 (Rev. 4-2023) Catalog Number 21563Q Department of the Treasury Internal Revenue Service www.irs.gov