Printable IRS 433-F Template

Form 433-F

(February 2019)

Department of the Treasury - Internal Revenue Service

Collection Information Statement

Name of Business

Business EIN

Type of Business

Number of Employees (not counting owner)

Name and Address of Institution

Account Number

Type of Account

Current

Balance/Value

Check if

Business Account

Name and Address of Institution

Account Number

Type of Account

Current

Balance/Value

Check if

Business Account

Type of Virtual Currency

Name of Virtual Currency Wallet,

Exchange or Digital Currency

Exchange (DCE)

Email Address Used to Set-up

With the Virtual Currency

Exchange or DCE

Location(s) of Virtual Currency (Mobile Wallet, Online, and/or External Hardware storage)

Virtual Currency

Amount and Value in US dollars as of today (e.g., 10 Bitcoins $64,600 USD)

Type

Credit Limit

Balance Owed

Minimum Monthly Payment

Credit Card

(Visa, Master Card, etc.)

Issuing Bank Name and Address

Merchant Account Number

Your current Employer (name and address)

Spouse’s current Employer (name and address)

How often are you paid (check one)

Alimony Income

Child Support Income

Net Self Employment Income

Net Rental Income

Unemployment Income

Pension Income

Interest/Dividends Income

Social Security Income

Other:

Your signature

Spouse’s signature

Date

What is the purpose of Form 433F?

Form 433-F is used to obtain current financial information necessary for determining how a wage earner or self-employed individual can satisfy an outstanding tax liability.

Note: You may be able to establish an Online Payment Agreement on the IRS web site. To apply online, go to https://www.irs.gov, click on “I need to pay my taxes,” and select “Installment Agreement” under the heading “What if I can't pay now?”

If you are requesting an Installment Agreement, you should submit Form 9465, Installment Agreement Request, along with Form 433-F. (A large down payment may streamline the installment agreement process, pay your balance faster and reduce the amount of penalties and interest.

Please retain a copy of your completed form and supporting documentation. After we review your completed form, we may contact you for additional information. For example, we may ask you to send supporting documentation of your current income or substantiation of your stated expenditures.

If any section on this form is too small for the information you need to supply, please use a separate sheet.

Section A – Accounts / Lines of Credit

List all accounts, even if they currently have no balance. However, do not enter bank loans in this section. Include business accounts, if applicable. If you are entering information for a stock or bond, etc. and a question does not apply, enter N/A.

Section B – Real Estate

List all real estate you own or are purchasing including your home. Include insurance and taxes if they are included in your monthly payment. The county/description is needed if different than the address and county you listed above. To determine equity, subtract the amount owed for each piece of real estate from its current market value.

Section C – Other Assets

List all cars, boats and recreational vehicles with their make, model and year. If a vehicle is leased, write “lease” in the “year purchased” column. List whole life insurance policies with the name of the insurance company. List other assets with a description such as “paintings”, “coin collection”, or “antiques”. If applicable, include business assets, such as tools, equipment, inventory, and intangible assets such as domain names, patents, copyrights, etc. To determine equity, subtract the amount owed from its current market value. If you are entering information for an asset and a question does not apply, enter N/A.

Section D – Credit Cards

List all credit cards and lines of credit, even if there is no balance owed.

Section E – Business Information

Complete this section if you or your spouse are self-employed, or have self-employment income. This includes self-employment income from online sales.

E1: List all Accounts Receivable owed to you or your business. Include federal, state and local grants and contracts.

E2: Complete if you or your business accepts credit card payments (e.g., Visa, MasterCard, etc.) and/or virtual currency wallet, exchange or digital currency exchange.

Section F – Employment Information

Complete this section if you or your spouse are wage earners.

If attaching a copy of current pay stub, you do not need to complete this section.

Section G – Non-Wage Household Income

List all non-wage income received monthly.

Net Self-Employment Income is the amount you or your

spouse earns after you pay ordinary and necessary monthly business expenses. This figure should relate to the yearly net profit from Schedule C on your Form 1040 or your current year profit and loss statement. Please attach a copy of Schedule C or your current year profit and loss statement. If net income is a loss, enter “0”.

Net Rental Income is the amount you earn after you pay ordinary and necessary monthly rental expenses. This figure should relate to the amount reported on Schedule E of your Form 1040.

Do not include depreciation expenses. Depreciation is a non-cash expense. Only cash expenses are used to determine ability to pay).

If net rental income is a loss, enter “0”.

Other Income includes distributions from partnerships and subchapter S corporations reported on Schedule K-1, and from limited liability companies reported on Form 1040, Schedule C, D or E. It also includes agricultural subsidies, gambling income, oil credits, and rent subsidies. Enter total distributions from IRAs if not included under Pension Income.

Section H – Monthly Necessary Living Expenses

Enter monthly amounts for expenses. For any expenses not paid monthly, convert as follows:

For expenses claimed in boxes 1 and 4, you should provide the IRS allowable standards, or the actual amount you pay if the amount exceeds the IRS allowable standards. IRS allowable standards can be found by accessing https://www.irs.gov/ businesses/small-businesses-self-employed/collection-financial- standards.

Substantiation may be required for any expenses over the standard once the financial analysis is completed.

The amount claimed for Miscellaneous cannot exceed the standard amount for the number of people in your family. The miscellaneous allowance is for expenses incurred that are not included in any other allowable living expense items. Examples are credit card payments, bank fees and charges, reading material and school supplies.

If you do not have access to the IRS web site, itemize your actual expenses and we will ask you for additional proof, if required. Documentation may include pay statements, bank and investment statements, loan statements and bills for recurring expenses, etc.

Housing and Utilities – Includes expenses for your primary residence. You should only list amounts for utilities, taxes and insurance that are not included in your mortgage or rent payments.

Rent – Do not enter mortgage payment here. Mortgage payment is listed in Section B.

Transportation – Include the total of maintenance, repairs, insurance, fuel, registrations, licenses, inspections, parking, and tolls for one month.

Public Transportation – Include the total you spend for public transportation if you do not own a vehicle or if you have public transportation costs in addition to vehicle expenses.

Medical – You are allowed expenses for health insurance and out-of-pocket health care costs.

Health insurance – Enter the monthly amount you pay for yourself or your family.

Out-of-Pocket health care expenses – are costs not

covered by health insurance, and include:

•Medical services

•Prescription drugs

•Dental expenses

•Medical supplies, including eyeglasses and contact lenses. Medical procedures of a purely cosmetic nature, such as plastic surgery or elective dental work are generally not allowed.

Child / Dependent Care – Enter the monthly amount you pay for the care of dependents that can be claimed on your Form 1040.

Estimated Tax Payments – Calculate the monthly

amount you pay for estimated taxes by dividing the quarterly amount due on your Form 1040ES by 3.

Life Insurance – Enter the amount you pay for term life insurance only. Whole life insurance has cash value and should be listed in Section C.

Delinquent State & Local Taxes – Enter the minimum

amount you are required to pay monthly. Be prepared to provide a copy of the statement showing the amount you owe and if applicable, any agreement you have for monthly payments.

Student Loans – Minimum payments on student loans for the taxpayer’s post-secondary education may be allowed if they are guaranteed by the federal government. Be prepared to provide proof of loan balance and payments.

Court Ordered Payments – For any court ordered

payments, be prepared to submit a copy of the court order portion showing the amount you are ordered to pay, the signatures, and proof you are making the payments. Acceptable forms of proof are copies of cancelled checks or copies of bank or pay statements.

Other Expenses not listed above – We may allow

other expenses in certain circumstances. For example, if the expenses are necessary for the health and welfare of the taxpayer or family, or for the production of income. Specify the expense and list the minimum monthly payment you are billed.