Get IRS 433-A (OIC) 2021

Form 433-A OIC Rev. January 2014 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 partnership liability income. Employer s Address street city state zip code Your Employer s Name Do you have an interest in this business Your Occupation How long with this employer years months Spouse s Employer s Name Does your spouse have an interest in this business Spouse s Occupation Catalog Number 55896Q www.irs.gov Form 433-A OIC Rev. 1-2014 Page 2 of 8 Personal Asset Information Cash and Investments domestic and foreign Use the most current statement for each type of account such as checking savings money market and online accounts stored value cards such as a payroll card from an employer investment and retirement accounts IRAs Keogh 401 k plans stocks bonds mutual funds certificates of deposit life insurance policies that have a cash value and safe deposit boxes. You are considered to be self-employed if you are in business for yourself or carry on a trade or business. An individual responsible for a Trust Fund Recovery Penalty Wage earners Complete Sections 1 2 3 7 8 9 and the signature line in Section 10. Note Include attachments if additional space is needed to respond completely to any question* Section 1 Personal and Household Information Last Name First Name Marital status Date of Birth mm/dd/yyyy Social Security Number Do you Home Address Street City State ZIP Code Unmarried Own your home Married Other specify e*g* share rent live with relative etc* County of Residence Primary Phone Mailing Address if different from above or Post Office Box number - Fax Number Secondary Phone Rent Provide information about your spouse. Spouse s Last Name Spouse s First Name Name Age Relationship Claimed as a dependent on your Form 1040 Contributes to household income Yes No Employment Information for Wage Earners 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 complete Business Information in Sections 4 5 and 6. Asset value is subject to adjustment by IRS based on individual circumstances. Enter the total amount available for each of the following if additional space is needed include attachments. Round to the nearest whole dollar. Do not enter a negative number. If any line item is a negative number enter 0. Cash Checking Savings Money Market/CD Bank Name Online Account Stored Value Card Account Number 1a 1b Total of bank accounts from attachment Add lines 1a through 1c less 1 000 Investment Account Stocks Bonds 1c Other Name of Financial Institution Current Market Value Less Loan Balance X. 8 2a 2b Total of investment accounts from attachment. current market value X. 8 less loan balance s 2c Retirement Account IRA X. 7 3a 3b 3c Cash Value of Life Insurance Policies Name of Insurance Company Current Cash Value Policy Number 4a 4b Total of life insurance policies from attachment Section 3 Continued Real Estate Enter information about any house condo co-op time share etc* that you own or are buying Property Address Street Address City State ZIP Code Primary Residence Date Purchased County and Country Date of Final Payment How title is held joint tenancy etc* Description of Property Total Value of Real Estate 5a 5b Total value of property s from attachment current market value X.