Form 433-A (OIC), Collection Information Statement for Wage Earners and Self-Employed Individuals Completed Form Examples and Samples

Explore detailed examples and samples of a completed IRS Form 433-A (OIC). Our filled-out templates for wage earners and self-employed individuals provide a clear guide on how to correctly complete the Collection Information Statement for an Offer in Compromise.
Form 433-A (OIC), Collection Information Statement for Wage Earners and Self-Employed Individuals has a very complex Form Complexity Index of 94/100 — Instafill’s AI completes it in under a minute.
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A completed sample of Form 433-A (OIC) for a self-employed individual applying for an Offer in Compromise.

Form 433-A (OIC) Example – Self-Employed Individual

How this form was filled:

This is an example of a completed Form 433-A (OIC) for a self-employed graphic designer seeking an Offer in Compromise. It details personal information, assets, self-employment income and expenses, and monthly living expenses to demonstrate the taxpayer's financial situation and inability to pay their full tax liability.

Information used to fill out the document:

  • Taxpayer Name: Jane M. Smith
  • Social Security Number: XXX-XX-1234
  • Address: 456 Oak Avenue, Anytown, CA 90210
  • Phone Number: (310) 555-0102
  • Filing Status: Single
  • Dependents: 1 (Son, age 10)
  • Occupation: Freelance Graphic Designer
  • Business Name: Jane Smith Designs
  • Gross Monthly Business Income: $6,500.00
  • Total Monthly Business Expenses: $1,500.00
  • Net Monthly Business Income: $5,000.00
  • Checking Account Balance: $1,250.00
  • Savings Account Balance: $500.00
  • Vehicle: 2020 Toyota Camry
  • Vehicle Fair Market Value: $18,000.00
  • Vehicle Loan Balance: $10,000.00
  • Total Monthly Living Expenses: $4,650.00 (Housing, Food, Transportation, Health Care)
  • Source of Funds for Offer: Loan from family member
  • Date: 01/20/2026

What this filled form sample shows:

  • Complete reporting of self-employment income and business expenses in Section 4.
  • Detailed declaration of personal assets, including bank accounts and vehicle equity, in Section 5.
  • Accurate application of IRS national and local standards for monthly living expenses in Section 7.
  • Clear calculation of monthly disposable income, which is fundamental to the OIC evaluation.
  • Proper identification of the source of funds for the offer amount.

Form specifications and details:

Use Case: Self-employed freelancer filing an Offer in Compromise (OIC) due to tax debt.
Form Name: Form 433-A (OIC)
Form Title: Collection Information Statement for Wage Earners and Self-Employed Individuals
Filing Agency: Internal Revenue Service (IRS)
Categories: self-employed forms, NJ state forms, PA state forms, state ID forms, wage forms
Created: March 07, 2026 01:07 AM
A completed sample of Form 433-A (OIC) for a self-employed individual applying for an Offer in Compromise.