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) 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) |
Created: March 07, 2026 01:07 AM
