Form 433-A (OIC), Collection Information Statement for Wage Earners and Self-Employed Individuals Instructions
This form contains 422 fields organized into 99 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| 24-Month Payment Calculation | ||
| Box F Total for 24-Month Calculation | Number |
Provide the total amount from Box F to be used in the 6 to 24 month payment calculation. Fill only if 'Box F' is calculated
Depends on:
Remaining Monthly Income
|
| Box H Future Remaining Income | Number |
Provide the calculated future remaining income for Box H, which is the total from Box F multiplied by 24. Fill only if 'Remaining Monthly Income' is calculated
Depends on:
Remaining Monthly Income
|
| 5-Month Payment Calculation | ||
| Box F Total | Number |
Please enter the total dollar amount from Box F. Fill only if 'Box F' is calculated
Depends on:
Remaining Monthly Income
|
| Box G Future Remaining Income | Number |
Please enter the calculated future remaining income for Box G. Fill only if 'Remaining Monthly Income' is calculated
Depends on:
Remaining Monthly Income
|
| Accounts Receivable Inquiry | ||
| Yes | Checkbox |
Check this box if you have accounts receivable, including e-payment, factoring companies, and any bartering or online auction accounts. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| No | Checkbox |
Check this box if you do not have accounts receivable, including e-payment, factoring companies, and any bartering or online auction accounts. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Applicable Attachments Checklist | ||
| Copies of the most recent pay stub, earnings statement, etc., from each employer. | Checkbox |
The user should check this box if they are including copies of their most recent pay stub or earnings statement from each employer.
|
| Copies of the most recent statement for each investment and retirement account. | Checkbox |
The user should check this box if they are including copies of their most recent statement for each investment and retirement account.
|
| Copies of all documents and records showing currently held digital assets. | Checkbox |
The user should check this box if they are including copies of all documents and records that show currently held digital assets.
|
| Copies of the most recent statement, etc., from all other sources of income such as pensions, Social Security, rental income, interest and dividends (including any received from a related partnership, corporation, LLC, LLP, etc.), court order for child support, alimony, royalties, agricultural subsidies, gambling income, oil credits, rent subsidies, sharing economy income from providing on-demand work, services or goods (e.g., Uber, Lyft, AirBnB, VRBO), income through digital platforms like an app or website, etc., and recurring capital gains from the sale of securities or other property such as digital assets. | Checkbox |
The user should check this box if they are including copies of the most recent statements or documentation from all other specified sources of income, including pensions, Social Security, rental income, investments, and various other forms of digital income or capital gains.
|
| Copies of individual complete bank statements for the three most recent months. If you operate a business, copies of the six most recent complete statements for each business bank account. | Checkbox |
The user should check this box if they are including copies of their individual complete bank statements for the three most recent months, or if operating a business, copies of the six most recent complete statements for each business bank account.
|
| Completed Form 433-B (Collection Information Statement for Businesses) if you or your spouse have an interest in a business entity other than a sole-proprietorship. | Checkbox |
The user should check this box if they or their spouse have an interest in a business entity other than a sole-proprietorship and are including a completed Form 433-B. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Copies of the most recent statement from lender(s) on loans such as mortgages, second mortgages, vehicles, etc., showing monthly payments, loan payoffs, and balances. | Checkbox |
The user should check this box if they are including copies of the most recent statements from lenders for loans such as mortgages, second mortgages, and vehicles, showing monthly payments, loan payoffs, and balances.
|
| List of Accounts Receivable or Notes Receivable, if applicable. | Checkbox |
The user should check this box if they are including a list of Accounts Receivable or Notes Receivable, and if applicable to their situation. Fill only if 'Do you have notes receivable' is 'Yes'.
Depends on:
Notes Receivable Yes
|
| Verification of delinquent State/Local Tax Liability showing total delinquent state/local taxes and amount of monthly payments, if applicable. | Checkbox |
The user should check this box if they are including verification of delinquent State/Local Tax Liability, showing total taxes and monthly payments, and if applicable. Fill only if 'Enter the amount of your monthly delinquent state and/or local tax payment(s).' is filled.
Depends on:
Monthly Delinquent Tax Payment
|
| Copies of court orders for child support/alimony payments claimed in monthly expense section. | Checkbox |
The user should check this box if they are including copies of court orders for child support or alimony payments that are claimed in the monthly expense section. Fill only if 'Court-ordered payments' is filled.
Depends on:
Monthly Court-ordered Payments
|
| Copies of Trust documents if applicable per Section 9. | Checkbox |
The user should check this box if they are including copies of Trust documents, and if applicable as per Section 9 of the form. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Documentation to support any special circumstances described in the "Explanation of Circumstances" on Form 656, if applicable. | Checkbox |
The user should check this box if they are including documentation to support any special circumstances described in the "Explanation of Circumstances" section on Form 656, and if applicable.
|
| Attach a Form 2848, Power of Attorney and Declaration of Representative, if you would like your attorney, CPA, or enrolled agent to represent you and you do not have a current form on file with the IRS. Ensure all years and forms involved in your offer are listed on Form 2848 and include the current tax year. | Checkbox |
The user should check this box if they are attaching Form 2848, Power of Attorney and Declaration of Representative, because they want their attorney, CPA, or enrolled agent to represent them and they do not have a current form on file with the IRS.
|
| Completed and signed current Form 656. | Checkbox |
The user should check this box if they are including a completed and signed current Form 656.
|
| Asset Transfer Question | ||
| Yes | Checkbox |
Check this box if, in the past 10 years, you have transferred any asset with a fair market value of more than $10,000, including real property, for less than its full value.
|
| No | Checkbox |
Check this box if, in the past 10 years, you have NOT transferred any asset with a fair market value of more than $10,000, including real property, for less than its full value.
|
| Asset Value Summary | ||
| Total Value of Assets from Attachment | Number |
Enter the total value of assets listed from an attachment, calculated as the current market value multiplied by 0.8 minus any loan balances. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Total Asset Value (Lines 9a-9c) | Number |
Enter the sum of the values from lines (9a) through (9c). Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| IRS Allowed Deduction (10) | Number |
Enter the IRS allowed deduction amount for professional books and tools of trade for individuals and sole-proprietors. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Net Asset Value (Line 9 minus Line 10) | Number |
Enter the calculated value of line (9) minus line (10), ensuring that if the result is less than zero, you enter zero. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Assets Outside U.S. Description | ||
| Assets Outside U.S. Description | Text |
Provide a detailed description of assets or real property owned outside the U.S., including their location and value. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Assets Outside U.S. Question | ||
| Yes | Checkbox |
Check this box if you have any assets or own any real property outside the U.S.
|
| No | Checkbox |
Check this box if you do not have any assets or own any real property outside the U.S.
|
| Available Business Equity in Assets | ||
| Available Business Equity in Assets | Number |
Provide the total amount of available business equity in assets, calculated by adding lines (8) and (11). Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Bank Account 1 Details | ||
| Bank Name and Country | Text |
Please provide the name of the bank and its country location.
|
| Account Number | Text |
Please enter the account number for this bank account.
|
| Account Value | Number |
Please provide the total value of this bank account.
|
| Bank Account 1 Type | ||
| Checkbox | ||
| Checking | Checkbox |
Check this box if the bank account you are reporting is a checking account.
|
| Savings | Checkbox |
Check this box if the bank account you are reporting is a savings account.
|
| Money Market Account/CD | Checkbox |
Check this box if the bank account you are reporting is a money market account or a certificate of deposit.
|
| Online Account | Checkbox |
Check this box if the bank account you are reporting is an online account.
|
| Stored Value Card | Checkbox |
Check this box if the bank account you are reporting is a stored value card.
|
| Bank Account 2 Details | ||
| Bank Account 2 Name and Country | Text |
Please provide the name of the bank and its country location for the second bank account.
|
| Bank Account 2 Number | Text |
Please enter the account number for the second bank account.
|
| Bank Account 2 Value | Number |
Please enter the total value of the second bank account, rounded to the nearest dollar.
|
| Bank Account 2 Type | ||
| Checking | Checkbox |
Check this box if the bank account is a checking account.
|
| Savings | Checkbox |
Check this box if the bank account is a savings account.
|
| Money Market Account/CD | Checkbox |
Check this box if the bank account is a money market account or a certificate of deposit (CD).
|
| Online Account | Checkbox |
Check this box if the bank account is an online account.
|
| Stored Value Card | Checkbox |
Check this box if the bank account is a stored value card.
|
| Bank Account Totals | ||
| Total Bank Accounts from Attachment | Number |
Enter the total monetary value of all bank accounts that are detailed in attached documents.
|
| Adjusted Bank Account Total | Number |
Enter the sum of the amounts from lines (1a), (1b), and (1c), then deduct one thousand dollars from this combined total.
|
| Bankruptcy History | ||
| Yes | Checkbox |
Check this box if you have filed for bankruptcy in the past 7 years.
|
| No | Checkbox |
Check this box if you have not filed for bankruptcy in the past 7 years.
|
| Date Filed | Date |
Enter the date the bankruptcy was filed. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Date Dismissed | Date |
Enter the date the bankruptcy was dismissed. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Date Discharged | Date |
Enter the date the bankruptcy was discharged. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Petition Number | Text |
Enter the bankruptcy petition number. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Location Filed | Text |
Enter the location where the bankruptcy was filed. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Beneficiary Information | ||
| Yes | Checkbox |
Check this box if you are the beneficiary of a trust, estate, or life insurance policy, including those located in foreign countries or jurisdictions.
|
| No | Checkbox |
Check this box if you are not the beneficiary of a trust, estate, or life insurance policy, including those located in foreign countries or jurisdictions.
|
| Place Where Recorded | Text |
Enter the location where the trust, estate, or policy is recorded. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Beneficiary EIN | Text |
Enter the Employer Identification Number (EIN) associated with the trust, estate, or policy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Name of Trust, Estate, or Policy | Text |
Enter the full name of the trust, estate, or life insurance policy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Anticipated Amount to be Received | Number |
Enter the anticipated monetary amount expected to be received from the trust, estate, or policy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| When Amount Will Be Received | Text |
Specify when the anticipated amount from the trust, estate, or policy is expected to be received. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Business Asset Value Summary | ||
| Total Bank Accounts from Attachment | Number |
Enter the total monetary value from bank accounts listed in an attachment for line 8d. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Total Business Assets (8a-8d) | Number |
Enter the sum of all values from lines 8a through 8d. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Business Digital Asset | ||
| Digital asset | Checkbox |
Check this box if the business owns or possesses any digital assets, such as cryptocurrency or NFTs. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Text | ||
| Text | ||
| Text | ||
| Text |
Depends on:
|
|
| Text |
Depends on:
|
|
| Text | ||
| Text | ||
| Business Expenses | ||
| Materials Purchased | Number |
Enter the total amount spent on materials directly related to the production of a product or service. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Inventory Purchased | Number |
Enter the total amount spent on goods purchased for resale. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Gross Wages and Salaries | Number |
Enter the total gross amount paid for wages and salaries. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Rent | Number |
Enter the total amount paid for business rent. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Supplies | Number |
Enter the total amount spent on supplies used to conduct business and used up within one year. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Utilities and Telephones | Number |
Enter the total amount paid for business utilities and telephone services. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Vehicle Costs | Number |
Enter the total amount of business vehicle costs, including gas, oil, repairs, and maintenance. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Business Insurance | Number |
Enter the total amount paid for business insurance. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Current Business Taxes | Number |
Enter the total amount paid for current business taxes, such as real estate, excise, franchise, occupational, personal property, sales, and employer's portion of employment taxes. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Secured Debts | Number |
Enter the total amount paid on secured business debts, excluding credit cards. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Other Business Expenses | Number |
Enter the total amount for any other business expenses not previously listed. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Total Business Expenses | Number |
Enter the sum of all business expenses from line (18) through line (28). Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Business Income | ||
| Gross Receipts | Number |
Enter the total amount of gross receipts from your business. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Gross Rental Income | Number |
Enter the total amount of gross rental income from your business. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Interest Income | Number |
Enter the total amount of interest income received by your business. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Dividends | Number |
Enter the total amount of dividends received by your business. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Other Income | Number |
Enter the total amount of other income not listed in the categories above for your business. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Total Business Income | Number |
Enter the sum of all business income from gross receipts, gross rental income, interest income, dividends, and other income. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Business Ownership Interest | ||
| Yes | Checkbox |
Check this box if you have an ownership interest in the business.
|
| No | Checkbox |
Check this box if you do not have an ownership interest in the business.
|
| Child/dependent Care Payments | ||
| Child Dependent Care Payments | Number |
Enter the total monthly amount paid for child and dependent care services, such as daycare.
|
| Community Property State History | ||
| Lived in Community Property State While Married | Checkbox |
Check this box if you were married and lived in Arizona, California, Idaho, Louisiana, New Mexico, Nevada, Texas, Washington, or Wisconsin within the last ten years. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Contact Information | ||
| County of Residence | Text |
Please provide the name of the county where you reside.
|
| Primary Phone | Text |
Please provide your primary telephone number, including the area code.
|
| Secondary Phone | Text |
Please provide any secondary or alternative telephone number, including the area code.
|
| FAX Number | Text |
Please provide your facsimile (FAX) number, including the area code.
|
| Home Mailing Address | Text |
Please provide your full home mailing address, especially if it differs from your home physical address or if you use a post office box number.
|
| Court-ordered Payments | ||
| Monthly Court-ordered Payments | Number |
Provide the monthly cost of any court-ordered payments, such as alimony or child support.
|
| Current Monthly Taxes | ||
| Current Monthly Taxes Amount | Number |
Provide the average monthly cost for federal, state, local, and personal property taxes.
|
| Delinquent Tax Payment | ||
| Total Tax Owed | Number |
Please provide the total amount of delinquent state and/or local tax owed.
|
| Monthly Delinquent Tax Payment | Number |
Please provide the amount of your monthly delinquent state and/or local tax payment.
|
| Digital Asset Account | ||
| Digital asset | Checkbox |
Check this box if you have a digital asset account, such as cryptocurrencies, NFTs, or other virtual currencies.
|
| Description of Digital Asset | Text |
Enter a concise description of the digital asset.
|
| Number of Units | Number |
Enter the total number of units for the digital asset.
|
| Location of Digital Asset | Text |
Provide the location where the digital asset is held, such as an exchange account or self-hosted wallet.
|
| Custodian/Broker Account Number | Text |
Enter the account number if the digital asset is held by a custodian or broker. Fill only if 'Location of Digital Asset' indicates assets are held by a custodian or broker.
Depends on:
Location of Digital Asset
|
| Self-Hosted Digital Asset Address | Text |
Provide the digital asset address for self-hosted digital assets. Fill only if 'Location of Digital Asset' indicates assets are self-hosted.
Depends on:
Location of Digital Asset
|
| US Dollar Equivalent Today | Number |
Enter the current US dollar equivalent value of the digital asset as of today.
|
| Total Digital Asset Value (2c) | Number |
Enter the calculated total US dollar equivalent value for the digital asset.
|
| First Asset Information | ||
| Asset Description | Text |
Enter a detailed description of the business asset. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Current Market Value | Number |
Enter the current market value of the asset. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Market Value X 0.8 | Number |
Enter the current market value of the asset multiplied by 0.8. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Minus Loan Balance | Number |
Enter the outstanding loan balance for the asset. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Total Asset Value | Number |
Enter the total value of the asset, which is calculated as (Current Market Value X 0.8) - Loan Balance. If the asset is leased or used in the production of income, enter 0. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| First Business Bank Account | ||
| Cash | Checkbox |
Check this box if the business asset being reported is held as cash. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Checking | Checkbox |
Check this box if the business asset being reported is held in a checking account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Savings | Checkbox |
Check this box if the business asset being reported is held in a savings account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Money Market/CD | Checkbox |
Check this box if the business asset being reported is held in a money market account or a certificate of deposit (CD). Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Online Account | Checkbox |
Check this box if the business asset being reported is held in an online account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Stored Value Card | Checkbox |
Check this box if the business asset being reported is held on a stored value card. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Bank Name and Country Location | Text |
Enter the name of the bank and its country location for this business account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Account Number | Text |
Provide the account number for this business bank account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Account Balance (8a) | Number |
Enter the current balance of the business bank account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| First Other Household Person | ||
| First Person's Name | Text |
Enter the full name of the first other person in the household or claimed as a dependent.
|
| First Person's Age | Text |
Enter the age of the first other person in the household or claimed as a dependent.
|
| First Person's Relationship | Text |
Enter the relationship of the first other person to the taxpayer.
|
| Claimed as a dependent on your Form 1040 (Yes) | Checkbox |
Check this box if the first person listed is claimed as a dependent on your Form 1040.
|
| Claimed as a dependent on your Form 1040 (No) | Checkbox |
Check this box if the first person listed is not claimed as a dependent on your Form 1040.
|
| Contributes to household income (Yes) | Checkbox |
Check this box if the first person listed contributes to your household income.
|
| Contributes to household income (No) | Checkbox |
Check this box if the first person listed does not contribute to your household income.
|
| First Real Property Information | ||
| Property Description | Text |
Enter a description of the real property, such as if it is a personal residence, rental property, or vacant land. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Purchase Date | Date |
Provide the date when the real property was purchased. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Mortgage Payment Amount | Number |
Enter the regular amount paid for the mortgage. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Final Payment Date | Date |
Provide the date when the final mortgage payment is due. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Title Holding Method | Text |
Specify how the title to the property is held, such as joint tenancy or sole ownership. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Property Location | Text |
Enter the full address of the real property, including street, city, state, ZIP code, county, and country. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Lender/Contract Holder Information | Text |
Provide the name, full address (street, city, state, ZIP code), and phone number of the lender or contract holder. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Current Market Value | Number |
Enter the current market value of the real property. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Eighty Percent of Market Value | Number |
Enter eighty percent of the current market value of the real property. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Loan Balance | Number |
Enter the outstanding loan balance for the mortgages or other debts on the property. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Total Value of Real Estate | Number |
Enter the total value of the real estate after subtracting the loan balance from eighty percent of its market value. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| First Vehicle Information | ||
| Vehicle Make & Model | Text |
Enter the make and model of the first vehicle. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Vehicle Year | Number |
Enter the manufacturing year of the first vehicle. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Date Purchased | Date |
Enter the date the first vehicle was purchased. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Mileage | Number |
Enter the total mileage of the first vehicle. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| License/Tag Number | Text |
Enter the license plate or tag number for the first vehicle. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Lease | Checkbox |
Check this box if the first vehicle is leased. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Own | Checkbox |
Check this box if the first vehicle is owned. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Name of Creditor | Text |
Enter the name of the creditor for the first vehicle's loan or lease. Fill only if 'Lease' is 'Yes'.
Depends on:
Lease
|
| Date of Final Payment | Date |
Enter the date of the final payment for the first vehicle's loan or lease. Fill only if 'Lease' is 'Yes'.
Depends on:
Lease
|
| Monthly Lease/Loan Amount | Number |
Enter the monthly lease or loan payment amount for the first vehicle. Fill only if 'Lease' is 'Yes'.
Depends on:
Lease
|
| Current Market Value | Number |
Enter the current market value of the first vehicle. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| 80% of Current Market Value | Number |
Enter 80% of the current market value of the first vehicle. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Minus Loan Balance | Number |
Enter the outstanding loan balance for the first vehicle. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Total Value of Vehicle (6a) | Number |
Enter the calculated total value of the vehicle; if the vehicle is leased, enter 0. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Adjusted Vehicle Value (6b) | Number |
Enter the result of subtracting $3,450 from line (6a); if the result is negative, enter 0. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Food, clothing, and miscellaneous Expenses | ||
| Text | ||
| Foreign Residency Information | ||
| Yes | Checkbox |
Check this box if you have lived outside of the U.S. for 6 months or longer in the past 10 years.
|
| No | Checkbox |
Check this box if you have NOT lived outside of the U.S. for 6 months or longer in the past 10 years.
|
| From Date | Date |
Enter the start date you lived outside the U.S. for 6 months or longer. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| To Date | Date |
Enter the end date you lived outside the U.S. for 6 months or longer. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Fourth Other Household Person | ||
| Fourth Other Household Person's Name | Text |
Please provide the full name of the fourth person in the household or claimed as a dependent.
|
| Fourth Other Household Person's Age | Number |
Please provide the age of the fourth person in the household or claimed as a dependent.
|
| Fourth Other Household Person's Relationship | Text |
Please provide the relationship of the fourth person to the taxpayer (e.g., child, parent, spouse) or claimed as a dependent.
|
| Claimed as a dependent (Yes) | Checkbox |
Check this box if the fourth listed household person is claimed as a dependent on your Form 1040.
|
| Claimed as a dependent (No) | Checkbox |
Check this box if the fourth listed household person is NOT claimed as a dependent on your Form 1040.
|
| Contributes to household income (Yes) | Checkbox |
Check this box if the fourth listed household person contributes to the household's income.
|
| Contributes to household income (No) | Checkbox |
Check this box if the fourth listed household person does NOT contribute to the household's income.
|
| Funds Held in Trust Details | ||
| Amount Held in Trust | Number |
Provide the total amount of funds being held in trust by a third party. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Trust Location | Text |
Specify the location or institution where the funds are being held in trust. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Funds Held in Trust Question | ||
| Yes | Checkbox |
Check this box if you have funds being held in trust by a third party.
|
| No | Checkbox |
Check this box if you do not have any funds being held in trust by a third party.
|
| Furniture and Personal Effects | ||
| Remaining Furniture & Personal Effects Description | Text |
Provide a description of the remaining furniture and personal effects not previously listed.
|
| Current Market Value | Number |
Enter the current market value of the described remaining furniture and personal effects.
|
| Market Value Multiplied by 0.8 | Number |
Enter the result of multiplying the current market value by 0.8.
|
| Loan Balance | Number |
Enter the outstanding loan balance for the described remaining furniture and personal effects.
|
| Net Value for Furniture & Personal Effects (7b) | Number |
Enter the calculated net value for the remaining furniture and personal effects for line (7b).
|
| General | ||
| Button | ||
| Button | ||
| Button | ||
| Health Insurance Premiums | ||
| Health Insurance Premiums | Number |
Enter the monthly amount for health insurance premiums.
|
| Housing and Utilities Expenses | ||
| Monthly Rent Payment | Number |
Enter the average monthly rent payment for housing if applicable. Fill only if 'Total Housing and Utilities' has a value representing a monthly rent payment.
Depends on:
Total Housing and Utilities
|
| Total Housing and Utilities | Number |
Enter the total average monthly cost for housing and utilities, including rent or mortgage payment, property taxes, home insurance, maintenance, dues, fees, and various utilities.
|
| Housing Information | ||
| Home Physical Address | Text |
Provide your complete home physical address, including street, city, state, and ZIP code.
|
| Own your home | Checkbox |
Check this box if you own your home.
|
| Rent | Checkbox |
Check this box if you rent your home.
|
| Other housing situation | Checkbox |
Check this box if your housing situation is neither owning nor renting, such as sharing rent or living with a relative.
|
| Other Housing Status Details | Text |
Specify your housing arrangement if you do not own or rent, for example, if you share rent or live with a relative. Fill only if 'Other housing situation' is 'Yes'.
Depends on:
Other housing situation
|
| Investment Account 1 Details | ||
| Financial Institution Name and Country | Text |
Enter the name of the financial institution where this investment account is held and its country location.
|
| Account Number | Text |
Enter the account number for this investment account.
|
| Current Market Value | Number |
Enter the current market value of this investment account.
|
| Loan Balance | Number |
Enter any outstanding loan balance associated with this investment account.
|
| Net Investment Value | Number |
Enter the net value of this investment account after subtracting any loan balance.
|
| Investment Account 1 Type | ||
| Stocks | Checkbox |
Check this box if the investment account type is Stocks.
|
| Bonds | Checkbox |
Check this box if the investment account type is Bonds.
|
| Other | Checkbox |
Check this box if the investment account type is Other.
|
| Investment Account Other Type | Text |
Please specify the type of investment account if 'Other' is selected. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Investment Account 2 Details | ||
| Financial Institution Name and Country | Text |
Enter the name of the financial institution where this investment account is held, along with its country and location.
|
| Account Number | Text |
Enter the account number for this investment account.
|
| Current Market Value | Number |
Enter the current market value of this investment account in US dollars, rounded to the nearest dollar.
|
| Loan Balance | Number |
Enter the outstanding loan balance associated with this investment account in US dollars, rounded to the nearest dollar.
|
| Net Investment Account Value (2b) | Number |
Enter the net value of this investment account, calculated by subtracting the loan balance from the current market value, in US dollars.
|
| Investment Account 2 Type | ||
| Stocks | Checkbox |
Check this box if the investment account type is Stocks.
|
| Bonds | Checkbox |
Check this box if the investment account type is Bonds.
|
| Other | Checkbox |
Check this box if the investment account type is Other.
|
| Investment Account 2 Other Account Number | Text |
Please provide the account number for this investment account if its type is 'Other'. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Investment Accounts Totals | ||
| Total Investment Accounts from Attachment | Number |
Enter the total current market value of all investment accounts listed in the attachment, minus any outstanding loan balances, for line (2d).
|
| Grand Total Investment Accounts | Number |
Enter the grand total of all investment account values by adding the amounts from lines (2a) through (2d).
|
| IRS Litigation Information | ||
| Types of Tax and Periods Involved | Text |
Enter the types of tax and the periods involved if the litigation included tax debt. Fill only if is 'Yes'.
Depends on:
|
| CheckBox | ||
| CheckBox | ||
| Life Insurance | ||
| Life Insurance Policy Amount | Number |
Enter the total amount of your life insurance policy. Fill only if 'Monthly Life Insurance Premiums' has a value.
Depends on:
Monthly Life Insurance Premiums
|
| Monthly Life Insurance Premiums | Number |
Enter the total monthly amount paid for life insurance premiums.
|
| Life Insurance Policy Details | ||
| Insurance Company Name | Text |
Enter the full legal name of the insurance company that issued the life insurance policy. Fill only if 'Self-employment income' is 'Yes'.
Depends on:
Yes
|
| Policy Number | Text |
Enter the unique policy number assigned to the life insurance policy. Fill only if 'Self-employment income' is 'Yes'.
Depends on:
Yes
|
| Current Cash Value | Number |
Enter the current cash value of the life insurance policy. Fill only if 'Self-employment income' is 'Yes'.
Depends on:
Yes
|
| Loan Balance | Number |
Enter the outstanding loan balance against the life insurance policy. Fill only if 'Self-employment income' is 'Yes'.
Depends on:
Yes
|
| Net Cash Value (4a) | Number |
This field represents the calculated net cash value for line (4a), which is the current cash value minus any outstanding loan balance for the life insurance policy. Fill only if 'Self-employment income' is 'Yes'.
Depends on:
Yes
|
| Life Insurance Totals | ||
| Total Cash Value From Attachment | Number |
Enter the total cash value of all life insurance policies as reported on the attachment. Fill only if 'Self-employment income' is 'Yes'.
Depends on:
Yes
|
| Loan Balance From Attachment | Number |
Enter the total loan balance(s) associated with life insurance policies as reported on the attachment. Fill only if 'Self-employment income' is 'Yes'.
Depends on:
Yes
|
| Net Cash Value (4b) | Number |
Enter the net cash value for line (4b), calculated by subtracting the loan balance(s) from the total cash value of life insurance policies from the attachment. Fill only if 'Self-employment income' is 'Yes'.
Depends on:
Yes
|
| Total Life Insurance Value (4) | Number |
Enter the grand total value of all life insurance policies, calculated by adding the amounts from lines (4a) and (4b). Fill only if 'Self-employment income' is 'Yes'.
Depends on:
Yes
|
| Litigation Information | ||
| Yes | Checkbox |
Check this box if you are a party to or involved in litigation.
|
| No | Checkbox |
Check this box if you are not a party to or involved in litigation.
|
| CheckBox |
Depends on:
Yes
|
|
| CheckBox |
Depends on:
Yes
|
|
| Location of Filing | Text |
Please enter the location where the litigation was filed. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Docket/Case Number | Text |
Please enter the docket or case number associated with the litigation. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Represented By | Text |
Please enter the name of the person or entity by whom you are represented in the litigation. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Possible Completion Date | Date |
Please enter the anticipated date when the litigation might be completed. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Subject of Litigation | Text |
Please enter a brief description of the subject or nature of the litigation. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Amount of Dispute | Number |
Please enter the total financial amount of the dispute in the litigation. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Marital Status | ||
| Unmarried | Checkbox |
Check this box if your current marital status is unmarried.
|
| Married | Checkbox |
Check this box if your current marital status is married.
|
| Date of Marriage | Date |
Provide the date of your marriage. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Minimum Offer Amount | ||
| Total Assets (Box A + Box B) | Number |
Provide the total amount from Box A plus Box B, if applicable. Fill only if 'Box B' is applicable
Depends on:
Second Asset Total Value (9b)
|
| Future Remaining Income | Number |
Provide the amount from either Box G or Box H.
|
| Minimum Offer Amount | Number |
Enter your minimum offer amount in whole dollars. The amount must be greater than zero.
|
| Net Business Income | ||
| Net Business Income | Number |
Provide the calculated net business income by subtracting the total business expenses (line 29) from the total business income (line 17). Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Notes Receivable Inquiry | ||
| Notes Receivable Yes | Checkbox |
Check this box if you have notes receivable and will attach a current listing. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Notes Receivable No | Checkbox |
Check this box if you do not have any notes receivable. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Other Business Interest Details | ||
| Percentage of Ownership | Number |
Enter the percentage of ownership held in this other business interest. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Title | Text |
Enter the title or role held within this other business interest. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Business Address | Text |
Provide the complete street address, city, state, and ZIP code for this other business interest. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Business Name | Text |
Enter the full legal name of this other business interest. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Business Telephone Number | Text |
Provide the telephone number for this other business interest. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Business EIN | Text |
Enter the Employer Identification Number (EIN) for this other business interest. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Business Interests Status | ||
| Yes | Checkbox |
Check this box if you or your spouse have other business interests, including any interest in an LLC, LLP, corporation, or partnership. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| No | Checkbox |
Check this box if neither you nor your spouse have any other business interests. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Other Household Income | ||
| Interest, Dividends, Royalties | Number |
Enter the total monthly income received from interest, dividends, and royalties.
|
| Net Rental Income | Number |
Enter the total monthly net income received from rental properties.
|
| Net Business Income (Box C) | Number |
Enter the total monthly net business income from Box C, ensuring that non-cash expenses like depreciation or depletion are added back into the income figure. Fill only if 'Self-Employed' is 'Yes'
Depends on:
Yes, Yes
|
| Child Support Received | Number |
Enter the total monthly child support payments received.
|
| Alimony Received | Number |
Enter the total monthly alimony payments received.
|
| Other Miscellaneous Income | Number |
Enter any other miscellaneous monthly income not specified in the categories above for line 38.
|
| Distributions Income | Number |
Enter the total monthly income received from distributions, such as income from partnerships or sub-S corporations.
|
| Additional Household Income Sources | Text |
List the sources of any additional income that supports the household, such as contributions from a non-liable spouse or other individuals.
|
| Other Valuable Item | ||
| Description of Asset | Text |
Provide a detailed description of the valuable asset(s).
|
| Current Market Value | Number |
Enter the current market value of the described asset(s).
|
| Market Value Multiplied by 0.8 | Number |
Enter the value obtained by multiplying the current market value by 0.8.
|
| Minus Loan Balance | Number |
Enter the outstanding loan balance against the asset(s).
|
| Net Asset Value (7a) | Number |
Enter the final calculated net value for the asset(s).
|
| Out-of-pocket Health Care Costs | ||
| Out-of-pocket Health Care Costs | Number |
Provide the average monthly cost of out-of-pocket health care expenses, such as prescription drugs, medical services, eyeglasses, and hearing aids.
|
| Period Provided | ||
| Period Beginning Date | Date |
Enter the beginning date of the period for which business income and expense information is provided. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Period Ending Date | Date |
Enter the ending date of the period for which business income and expense information is provided. Fill only if 'You or your spouse are self-employed' is Yes
Depends on:
Yes, Yes
|
| Personal Asset Value Summary | ||
| Total Valuable Items from Attachment | Number |
Provide the total value of valuable items listed from the attachment, calculated as current market value multiplied by 0.8 minus any loan balance.
|
| Net Value After IRS Deduction | Number |
Provide the sum of lines (7a) through (7c) minus the IRS deduction of $11,710.
|
| Available Individual Equity in Assets | Number |
Provide the total amount by adding lines (1) through (7) and entering it into Box A.
|
| Personal Information | ||
| Last Name | Text |
Please provide your last name.
|
| First Name | Text |
Please provide your first name.
|
| Date of Birth | Date |
Please enter your date of birth.
|
| Social Security Number or ITIN | Text |
Please provide your Social Security Number or Individual Taxpayer Identification Number.
|
| Primary Taxpayer Income | ||
| Primary Taxpayer Gross Wages | Number |
Provide the primary taxpayer's average gross monthly wages.
|
| Primary Taxpayer Social Security | Number |
Provide the primary taxpayer's average monthly Social Security income.
|
| Primary Taxpayer Pension Income | Number |
Provide the primary taxpayer's average monthly income from pensions.
|
| Primary Taxpayer Other Income | Number |
Provide the primary taxpayer's average monthly income from other sources, such as unemployment.
|
| Total Primary Taxpayer Income | Number |
Provide the calculated total average monthly income for the primary taxpayer.
|
| Public Transportation Costs | ||
| Monthly Public Transportation Costs | Number |
Enter the average monthly cost of fares for mass transit, such as bus, train, or ferry, for which a reasonable estimate may be used.
|
| Real Property Sale Status | ||
| Yes | Checkbox |
Check this box if your real property is currently for sale or if you anticipate selling it to fund the offer amount. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Listing Price | Number |
Provide the current listing price of the real property. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No | Checkbox |
Check this box if your real property is not currently for sale and you do not anticipate selling it to fund the offer amount. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Remaining Monthly Income | ||
| Remaining Monthly Income | Number |
Provide the calculated remaining monthly income by subtracting the total household expenses (Box E) from the total household income (Box D).
|
| Retirement Account Details | ||
| Financial Institution Name and Country | Text |
Enter the name of the financial institution where the retirement account is held, along with its country location.
|
| Account Number | Text |
Enter the account number for the retirement account.
|
| Current Market Value | Number |
Enter the current market value of the retirement account.
|
| Current Market Value x 0.8 | Number |
Enter the current market value of the retirement account multiplied by 0.8.
|
| Minus Loan Balance | Number |
Enter any outstanding loan balance associated with the retirement account.
|
| Line 3a Total | Number |
Enter the calculated total for line 3a, which is the current market value multiplied by 0.8 minus any loan balance.
|
| Retirement Account Totals | ||
| Attached Retirement Accounts Total | Number |
Enter the total value of retirement accounts reported in attachments, after applying the current market value multiplied by 0.8 minus any loan balances.
|
| Total Retirement Accounts Sum | Number |
Enter the sum of values from line (3a) and the attached retirement accounts total from line (3b).
|
| Retirement Account Type | ||
| 401K | Checkbox |
Check this box if the retirement account is a 401(k) plan.
|
| IRA | Checkbox |
Check this box if the retirement account is an Individual Retirement Account (IRA).
|
| Other | Checkbox |
Check this box if the retirement account type is not 401(k) or IRA, and then specify the type in the provided space.
|
| Other Retirement Account Type | Text |
Specify the type of retirement account if 'Other' is selected. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Safe Deposit Box Information | ||
| Yes | Checkbox |
Check this box if you have a safe deposit box (business or personal), including those located in foreign countries or jurisdictions.
|
| No | Checkbox |
Check this box if you do not have a safe deposit box (business or personal).
|
| Safe Deposit Box Location | Text |
Provide the name, address, and box number(s) of the safe deposit box. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Safe Deposit Box Contents | Text |
Describe the contents stored in the safe deposit box. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Safe Deposit Box Contents Value | Number |
Enter the monetary value of the contents held in the safe deposit box. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Second Asset Information | ||
| Second Asset Description | Text |
Provide a brief description of the second business asset. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Second Asset Current Market Value | Number |
Enter the current market value of the second business asset. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Second Asset Adjusted Value | Number |
Enter the current market value of the second business asset multiplied by 0.8. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Second Asset Loan Balance | Number |
Enter the outstanding loan balance for the second business asset. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Second Asset Total Value (9b) | Number |
Enter the total value for the second business asset, considering its market value, loan balance, and whether it's leased or used in income production. Fill only if 'you or your spouse are self-employed' is 'Yes'.
Depends on:
Yes, Yes
|
| Second Business Bank Account | ||
| Cash | Checkbox |
Check this box if the second business bank account you are reporting is a cash account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Checking | Checkbox |
Check this box if the second business bank account you are reporting is a checking account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Savings | Checkbox |
Check this box if the second business bank account you are reporting is a savings account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Money Market/CD | Checkbox |
Check this box if the second business bank account you are reporting is a Money Market or Certificate of Deposit (CD) account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Online Account | Checkbox |
Check this box if the second business bank account you are reporting is an online account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Stored Value Card | Checkbox |
Check this box if the second business bank account you are reporting is a stored value card. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Second Business Bank Name and Country | Text |
Please provide the name of the bank and its country location for the second business bank account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Second Business Bank Account Number | Text |
Please provide the account number for the second business bank account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Second Business Bank Account Balance | Number |
Please provide the current balance of the second business bank account. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Second Other Household Person | ||
| Second Other Household Person Name | Text |
Enter the full name of the second other person in the household or claimed as a dependent.
|
| Second Other Household Person Age | Text |
Enter the current age of the second other person in the household or claimed as a dependent.
|
| Second Other Household Person Relationship | Text |
Enter the relationship of the second other person to you (e.g., child, parent, sibling, roommate, etc.).
|
| Claimed as a Dependent on your Form 1040 - Yes | Checkbox |
Check this box if the second other household person is claimed as a dependent on your Form 1040.
|
| Claimed as a Dependent on your Form 1040 - No | Checkbox |
Check this box if the second other household person is not claimed as a dependent on your Form 1040.
|
| Contributes to Household Income - Yes | Checkbox |
Check this box if the second other household person contributes to the household income.
|
| Contributes to Household Income - No | Checkbox |
Check this box if the second other household person does not contribute to the household income.
|
| Second Real Property Information | ||
| Property Description | Text |
Enter a description of the real property, indicating its type (e.g., personal residence, rental property, or vacant). Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Purchase Date | Date |
Enter the date the real property was purchased. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Mortgage Payment Amount | Number |
Enter the amount of the monthly mortgage payment for the real property. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Final Payment Date | Date |
Enter the date of the final mortgage payment. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Title Holding | Text |
Enter how the title to the real property is held (e.g., joint tenancy). Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Property Location | Text |
Enter the full street address, city, state, ZIP code, county, and country where the real property is located. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Lender/Contract Holder Information | Text |
Enter the name, address (street, city, state, ZIP code), and phone number of the lender or contract holder for the real property. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Current Market Value | Number |
Enter the current market value of the real property. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Current Market Value Multiplied by 0.8 | Number |
Enter the current market value of the real property multiplied by 0.8. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Loan Balance | Number |
Enter the total outstanding loan balance for all mortgages on the real property. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Total Value of Real Estate (5b) | Number |
Enter the total calculated value of the real property for line (5b). Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Second Vehicle Information | ||
| Vehicle Make and Model | Text |
Enter the make and model of the second vehicle. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Vehicle Year | Text |
Enter the manufacturing year of the second vehicle. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Date Purchased | Date |
Enter the date the second vehicle was purchased. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Mileage | Number |
Enter the current mileage of the second vehicle. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| License/Tag Number | Text |
Enter the license plate or tag number for the second vehicle. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Lease | Checkbox |
Check this box if the second vehicle is leased. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Own | Checkbox |
Check this box if the second vehicle is owned. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Name of Creditor | Text |
Enter the name of the creditor for the second vehicle's loan or lease. Fill only if 'Lease' is 'Yes'.
Depends on:
Lease
|
| Date of Final Payment | Date |
Enter the date of the final payment for the second vehicle's loan or lease. Fill only if 'Lease' is 'Yes'.
Depends on:
Lease
|
| Monthly Lease/Loan Amount | Number |
Enter the monthly lease or loan payment amount for the second vehicle. Fill only if 'Lease' is 'Yes'.
Depends on:
Lease
|
| Current Market Value | Number |
Enter the current market value of the second vehicle. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Current Market Value x 0.8 | Number |
Enter the current market value of the second vehicle multiplied by 0.8. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Loan Balance | Number |
Enter the outstanding loan balance for the second vehicle. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Total Value of Vehicle (6c) | Number |
Enter the total value of the second vehicle from line (6c). Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Net Value After Deduction (6d) | Number |
Enter the net value from line (6d) after any applicable deduction. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Secured Debts/Other Expenses | ||
| Secured Debts/Other Expenses | Number |
Enter the total amount for secured debts or other expenses, such as loans with collateral, government-guaranteed student loans, or employer-required retirement contributions.
|
| Secured Debts/Other Expense List | Text |
Provide a detailed list of secured debts or other expenses included in this category, such as loans with collateral, government-guaranteed student loans, or employer-required retirement contributions. Fill only if 'Secured Debts/Other Expenses' has a value.
Depends on:
Secured Debts/Other Expenses
|
| Self-Employed Business Information | ||
| Text | ||
| Business Address | Text |
Please provide the physical street address of the business, if it is different from your personal residence. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Business Telephone Number | Text |
Please provide the primary telephone number for the business. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Employer Identification Number (EIN) | Text |
Please provide the Employer Identification Number (EIN) assigned to the business by the IRS. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Business Website Address | Text |
Please provide the website address for the business. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Trade Name or DBA | Text |
Please provide any trade name or 'Doing Business As' (DBA) name used by the business, if applicable. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Business Description | Text |
Please provide a brief description of the type of business or services offered. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Total Number of Employees | Number |
Please provide the total number of employees working for the business. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Frequency of Tax Deposits | Text |
Please specify how often the business makes tax deposits. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Average Gross Monthly Payroll | Number |
Please provide the average total amount of gross payroll paid by the business per month. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Sole Proprietorship Status | ||
| Yes | Checkbox |
Check this box if your business is a sole proprietorship. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| No | Checkbox |
Check this box if your business is not a sole proprietorship. Fill only if 'Do you have an ownership interest in this business' is 'Yes'.
Depends on:
Yes
|
| Spouse Income | ||
| Spouse Gross Wages | Number |
Enter the spouse's average gross monthly wages. Fill only if 'Married' is 'Yes'
Depends on:
Married
|
| Spouse Social Security | Number |
Enter the spouse's average monthly social security income. Fill only if 'Married' is 'Yes'
Depends on:
Married
|
| Spouse Pension(s) | Number |
Enter the spouse's average monthly pension income. Fill only if 'Married' is 'Yes'
Depends on:
Married
|
| Spouse Other Income | Number |
Enter the spouse's average monthly income from other sources, such as unemployment. Fill only if 'Married' is 'Yes'
Depends on:
Married
|
| Total Spouse Income | Number |
Enter the total average monthly income for the spouse, calculated as the sum of all other spouse income categories. Fill only if 'Married' is 'Yes'
Depends on:
Married
|
| Spouse Information | ||
| Spouse's Last Name | Text |
Enter your spouse's last name. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Spouse's First Name | Text |
Enter your spouse's first name. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Spouse's Date of Birth | Date |
Enter your spouse's date of birth. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Spouse's Social Security Number | Text |
Enter your spouse's Social Security Number. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Spouse Signature Date | ||
| Spouse Signature Date | Date |
Provide the date the spouse signed the form.
|
| Spouse's Business Ownership Interest | ||
| Yes | Checkbox |
Check this box if your spouse has an ownership interest in a business, and remember to complete and submit Form 433-B. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| No | Checkbox |
Check this box if your spouse does not have an ownership interest in any business. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Spouse's Employment Information | ||
| Spouse's Employer Name | Text |
Enter the full legal name of your spouse's employer. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Weekly | Checkbox |
Check this box if the spouse's employer pays them weekly. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Bi-weekly | Checkbox |
Check this box if the spouse's employer pays them bi-weekly. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Monthly | Checkbox |
Check this box if the spouse's employer pays them monthly. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Other | Checkbox |
Check this box if the spouse's employer pays them on a schedule other than weekly, bi-weekly, or monthly. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Spouse's Employer Address | Text |
Enter the full street address, city, state, and ZIP code of your spouse's employer. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Spouse's Occupation and Tenure | ||
| Spouse's Occupation | Text |
Enter your spouse's occupation or job title. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Spouse's Tenure Years | Text |
Enter the number of years your spouse has been with this employer. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Spouse's Tenure Months | Text |
Enter the number of months your spouse has been with this employer. Fill only if 'Married' is 'Married'.
Depends on:
Married
|
| Taxpayer Signature Date | ||
| Taxpayer Signature Date | Date |
Please enter the date the taxpayer signed the form.
|
| Third Other Household Person | ||
| Third Person's Name | Text |
Enter the full name of the third other person in the household or claimed as a dependent.
|
| Third Person's Age | Text |
Enter the age of the third other person in the household or claimed as a dependent.
|
| Third Person's Relationship | Text |
Enter the relationship of the third other person to the taxpayer (e.g., child, parent, other).
|
| Claimed as Dependent on Form 1040 (Yes) | Checkbox |
Check this box if the third other household person is claimed as a dependent on your Form 1040.
|
| Claimed as Dependent on Form 1040 (No) | Checkbox |
Check this box if the third other household person is not claimed as a dependent on your Form 1040.
|
| Contributes to Household Income (Yes) | Checkbox |
Check this box if the third other household person contributes to the household income.
|
| Contributes to Household Income (No) | Checkbox |
Check this box if the third other household person does not contribute to the household income.
|
| Total Household Expenses | ||
| Total Household Expenses | Number |
Enter the total sum of all monthly household expenses from lines 39 through 51.
|
| Total Household Income | ||
| Total Household Income | Number |
Provide the total monthly household income by adding the amounts from lines 30 through 38.
|
| Total Real Property Value | ||
| Total Value of Property From Attachment | Number |
Provide the total calculated value for properties detailed on an attachment, derived from the current market value multiplied by 0.8 minus any loan balance. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Grand Total Real Property Value | Number |
Provide the sum of the total real estate values from lines (5a), (5b), and (5c). Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Total Vehicle Value | ||
| Total Value from Attachment | Number |
Provide the total value of vehicles listed from any attachments, calculated as 80% of current market value minus any loan balances. Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Total Vehicle Value | Number |
Provide the grand total value of all vehicles, calculated by summing lines (6b), (6d), and (6e). Fill only if 'Has Self-Employment Income' is 'Yes'
Depends on:
Yes
|
| Transferred Asset Details | ||
| Asset(s) List | Text |
Provide a list of the asset(s) that were transferred. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Value at Transfer | Number |
Enter the value of the asset at the time of transfer. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Date Transferred | Date |
Provide the date the asset was transferred. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Transferee or Location | Text |
Specify to whom or where the asset was transferred. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Trustee Information | ||
| Yes | Checkbox |
Check this box if you are a trustee, fiduciary, or contributor of a trust.
|
| No | Checkbox |
Check this box if you are not a trustee, fiduciary, or contributor of a trust.
|
| Trust EIN | Text |
Please enter the Employer Identification Number (EIN) for the trust. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Trust Name | Text |
Please provide the name of the trust. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Type of Business | ||
| Partnership | Checkbox |
Check this box if the business is structured as a partnership. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| LLC | Checkbox |
Check this box if the business is structured as a Limited Liability Company (LLC). Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Corporation | Checkbox |
Check this box if the business is structured as a corporation. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other | Checkbox |
Check this box if the business type is not Partnership, LLC, or Corporation. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Business Type | Text |
Please specify the type of business if it is not a Partnership, LLC, or Corporation. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Vehicle Expenses | ||
| Vehicle Loan/Lease Payment | Number |
Enter the average monthly cost for vehicle loan and/or lease payments.
|
| Vehicle Operating Costs | Number |
Enter the average monthly cost of vehicle operating expenses, including maintenance, repairs, insurance, fuel, registrations, licenses, inspections, parking, and tolls.
|
| Your Employment Information | ||
| Your Employer's Name | Text |
Please provide the full legal name of your employer.
|
| Weekly | Checkbox |
Check this box if your employer pays you on a weekly basis.
|
| Bi-weekly | Checkbox |
Check this box if your employer pays you on a bi-weekly basis.
|
| Monthly | Checkbox |
Check this box if your employer pays you on a monthly basis.
|
| Other | Checkbox |
Check this box if your employer pays you on a schedule other than weekly, bi-weekly, or monthly.
|
| Your Employer's Address | Text |
Please provide the full street, city, state, and ZIP code for your employer's address.
|
| Your Occupation and Tenure | ||
| Your Occupation | Text |
Please provide your current occupation or job title.
|
| Tenure Years | Number |
Enter the number of years you have been employed with this employer.
|
| Tenure Months | Number |
Enter the number of months you have been employed with this employer beyond the full years.
|