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 selfemployment 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. 4-2024) Catalog Number 21563Q Department of the Treasury Internal Revenue Service www.irs.gov
TOTAL INCOME 

Items 20 and 21 – Wages

Enter your gross monthly wages and/or salaries. Do not deduct 

withholding or allotments taken out of your pay such as insurance, union 

dues, car payments, etc. List these deductions in Total Living Expenses.

Item 23 – Net Business Income

Enter your monthly net business income from line 89 on page 6.

Item 25 – Distributions

Enter the monthly average of your distributions from Partnerships, 

Subchapter S Corporations or Limited Liability Companies. Enter 401K 

distributions if not included in Pension Income on lines 26 or 27.

TOTAL LIVING EXPENSES (necessary)

To be necessary, expenses must provide for the health and welfare 

of you and your family and/or provide for the production of 

income, and must be reasonable in amount. We may ask you to 

provide substantiation of certain expenses.

Item 35 – Standard for Food, Clothing and Misc.

Enter the total amount for this item from the chart in the next 

column. If you claim a higher amount for a specific expense, you 

must verify and substantiate that amount. The miscellaneous 

allowance is for expenses that are not included in any other 

allowable living expense items (e.g., credit card payments, bank 

fees, school supplies, etc.).

Item 36 – Housing and Utilities

Enter the monthly rent or mortgage payment for your principal 

residence. Add the average monthly payment for the following 

expenses, if they are not included in your rent or mortgage 

payments: property taxes, homeowner’s or renter’s insurance, 

necessary maintenance and repair, homeowner dues, 

condominium fees and utilities.

Item 37 – Vehicle Ownership Costs

Enter your monthly lease, purchase or loan payments.

Item 38 – Vehicle Operating Costs

Enter the average monthly costs for insurance, licenses, 

registration fees, inspections, normal repairs and maintenance, 

fuel, parking and tolls.

Item 39 – Public Transportation

Enter the average monthly public transportation expenses you pay 

for bus, train and taxi fares, and any other mass transit fares. 

Item 40 – Health Insurance 

Enter your monthly expense for health insurance.

Item 41– Out-of-Pocket Health Care Costs

Enter the amount for this item from the chart in the next column. 

These are health care costs not covered by insurance. If you claim 

a higher amount, you must verify and substantiate the expenses.

Item 42 – Court Ordered Payments

Include child support, alimony, etc.

Item 45 – Current Year Taxes

Include state and Federal taxes withheld from salary or wages, 

or paid as estimated taxes. If applicable, include county, city, and 

municipal income taxes.

Item 46 – Secured Debts

Enter your average monthly payments for any other secured debts. 

Do not duplicate mortgage or car payments entered in Items 36 or 

37 above.

Item 48 – Other Expenses

In certain circumstances, IRS may allow minimum payments on 

other expenses, such as student loans, unsecured debts, tuition 

or contributions if required for employment, etc. Attach a list and 

explanation.

Total Monthly National Standards for Food, Clothing and Misc. 

(Section 5, item 35)

Effective 04/22/2024

Expense One 

Person

Two 

Persons

Three 

Persons

Four 

Persons

Food $458 $820 $977 $1,143 

Housekeeping supplies $44 $75 $83 $82 

Apparel & services $87 $157 $187 $300 

Personal care products 

& services

$48 $80 $87 $97

Miscellaneous $171 $279 $343 $405 

Total $808 $1,411 $1,677 $2,027 

More than four persons Over Four Persons Amount

For each additional person, add to 

four-person total allowance: $386 

To calculate the allowance, please read across to the column that 

matches the number of persons in your family.

When you have more than four persons in your family, you need to 

multiply the amount of additional persons over four by the dollar 

amount in the “Over Four” column; then add the answer to the 

dollar amount in the “Four” column. For example, when you have 

six persons in your family, you would multiply $386 by the two 

members of your family over four to get $772. You then would add 

this $772 to the $2,027 allowed for a family of four. As a result, 

your allowed expenses would equal $2,799 ($772 + $2,027).

Total Monthly National Standards for Out-of-Pocket 

Health Care Costs (Section 5, item 41)

Effective 04/22/2024

Out-of-Pocket Health Care Costs

Under 65 $83

65 and Older $158

To calculate the allowance, determine the number and age of 

persons in your household and multiply by the amount reflected in 

the chart.

For example, a family of three persons, all under 65, would be 

allowed $249 ($83 x 3).

NOTE: IRS will allow reasonable expenses that exceed the 

standards if using the standards is not adequate to provide for 

your necessary living expenses. You may be asked to provide 

verification of expenses claimed.