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Form 433-A
Form 433-A
Form 433-A (OIC)
(Rev. May 2012)
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 personally responsible for a
partnership liability
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.
Self-employed individuals Complete all sections and signature line on page 7
Note: Include attachments if additional space is needed to respond completely to any question.
Section 1 Personal and Household Information
Last Name First Name
Date of Birth
(mm/dd/yyyy) Social Security Number
Marital status
Married
Unmarried
Home Address
(Street, City, State, ZIP Code)
Do you:
Own your home Rent
Other
(specify e.g., share rent, live with relative, etc.)
County of Residence
Primary Phone
( )
-
Secondary Phone
( )
-
Fax Number
( )
-
Mailing Address
(if different from above or Post Office Box number)
Employer's Name
Occupation
How Long
Employer's Address
(Street, City, State, ZIP Code)
Provide information about your spouse.
Spouse's Last Name First Name
Date of Birth
(mm/dd/yyyy)
Social Security Number
Occupation
Employer's Name
Employer's Address
(Street, City, State, ZIP Code)
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
Section 2 Self-employed Information
If you or your spouse is self-employed, complete this section.
Is your business a sole proprietorship
(filing Schedule C)
Yes No
Name of Business
Address of Business
(If other than personal residence)
Business Telephone Number
( )
-
Employer Identification Number
Business Website
Description of Business Total Number of Employees
Frequency of Tax Deposits
Average Gross Monthly
Payroll $
Trade Name or dba
Catalog Number 55896Q
www.irs.gov
Form
433-A (OIC) (Rev. 5-2012)
Wage earners Complete sections 1, 3, 4 (Box 1), 6, and 7 including signature line on page 7.
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