Form 433-F (Rev. 7-2024), Collection Information Statement Completed Form Examples and Samples

Explore comprehensive examples and samples of a completed IRS Form 433-F (Rev. 7-2024), Collection Information Statement. Our detailed guides illustrate how to accurately fill out the form for various financial situations, helping you prepare for discussions with the IRS.
Form 433-F (Rev. 7-2024), Collection Information Statement has a very complex Form Complexity Index of 84/100 — Instafill’s AI completes it in under a minute.
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Completed Form 433-F (Rev. 7-2024), Collection Information Statement for a married couple with dependents.

Form 433-F (Rev. 7-2024) Example: Married Couple with Dependents

How this form was filled:

This sample Form 433-F is filled out for a married couple, John and Jane Smith, who have two dependents. It details their joint income from two jobs, their primary residence with a mortgage, two vehicles (one with a loan), and their monthly living expenses. This example illustrates how to provide a complete financial picture to the IRS when seeking a collection alternative.

Information used to fill out the document:

  • Taxpayer Name: John A. Smith
  • Taxpayer SSN: 000-11-2222
  • Spouse Name: Jane B. Smith
  • Spouse SSN: 000-33-4444
  • Address: 456 Oak Avenue, Anytown, USA 12345
  • Dependents: 2 Children (Ages 8 and 12)
  • Taxpayer's Employer: Reliable Auto Repair
  • Spouse's Employer: Anytown School District
  • Total Monthly Gross Income: $6,500
  • Total Monthly Net Income: $5,150
  • Total Monthly Living Expenses: $4,950
  • Primary Residence Fair Market Value: $350,000
  • Mortgage Balance: $280,000
  • Vehicle 1 (2022 SUV) Value: $25,000
  • Vehicle 1 Loan Balance: $15,000
  • Vehicle 2 (2018 Sedan) Value: $12,000
  • Vehicle 2 Loan Balance: $0
  • Bank Account (Checking) Balance: $2,800
  • Bank Account (Savings) Balance: $700
  • Credit Card Debt: $8,500
  • Signature Date: 01/15/2026

What this filled form sample shows:

  • Demonstrates how a married couple filing jointly reports their combined financial information.
  • Includes common assets like a primary residence and vehicles, showing how to list fair market value and outstanding loan balances.
  • Provides a realistic breakdown of monthly household income and living expenses for a family with dependents.
  • Accurately completed with taxpayer, spouse, and dependent information required for IRS collection evaluation.

Form specifications and details:

Form Name: Form 433-F (Rev. 7-2024), Collection Information Statement
Use Case: Married couple with two dependents providing financial information to the IRS to arrange a payment plan for back taxes.
Categories: NJ state forms, PA state forms, state ID forms
Created: February 11, 2026 07:40 PM
Completed Form 433-F (Rev. 7-2024), Collection Information Statement for a married couple with dependents.