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) 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. |
Created: February 11, 2026 07:40 PM
