How to Fill Out Form 433-A Collection Information Statement for Individuals

The following information is absolutely required to be attached to your Form 433-A when submitting an Offer in Compromise. Failure to include the information will automatically result in your Offer being returned to you for failure to meet the filing requirements. Some of the information may not pertain to you; for example, if you do not have any life insurance, then you will not be required to provide that information. If the information is not provided, then you must write "N/A" (not applicable) in the spaces of Form 433-A that do not apply.

Failure to complete all entry spaces on form 433-A may result in rejection or significant delay in the Offer process.

You may use this page as a checklist for the information you should provide.

If you have any doubt about whether or not to include a copy of any particular document, then go ahead and include it. It's better to send too much paperwork than not enough.

Do not send any original documents - send copies only.

Keep a complete copy (for your own records) of the entire package you send to IRS.

Section 1 Personal Information Section 2 Your Business Information
  • Proof of self-employment income for the prior 3 months (invoices, commissions, sales records, income statements).

Section 3 Employment Information

  • Proof of gross earnings and deductions for the past 3 months from each employer. May be in the form of pay stubs or earnings statements.
  • If year-to-date information is available, you may send only 1 statement as long as a minimum of 3 months is provided.

Section 4 Other Income Information

  • Proof of pension/Social Security/other income For the past 3 months for each payer.
  • Include and statements showing deductions.
  • If year-to-date information is available, you may send only 1 statement as long as a minimum of 3 months is provided.

Section 5 Banking, Investment, Cash, Credit, and Life Insurance Information

  • Copies of your current bank statements (checking, savings, money market, and brokerage accounts) for the past 3 months for all accounts.
  • A statement from your life insurance companies that includes type and cash/loan value amounts.
  • If life insurance is currently borrowed against, include the loan amount and date of loan.

Section 6 Other Information

  • If you answer yes to any questions in this section, you should provide supporting documentation.

Section 7 Assets and Liabilities

  • Include your current statement from your lender with your monthly car payment amount and current balance of the loan for each vehicle purchased or leased.
  • Include your current statement from your lender with your monthly house or other real estate payment amount and current balance for each piece of real estate owned.

Section 8 Accounts/Notes Receivable

Section 9 Monthly Income and Expense Analysis

  • Include a copy of your last Form 1040 with all schedules.
  • Include proof of all current expenses that you paid for the past 3 months, including:
  • rent or house payment
  • utilities
  • insurance
  • property taxes
  • other
  • Proof of all non-business transportation expenses for the last 3 months, including:
  • car payments
  • lease payments
  • fuel
  • oil
  • insurance
  • parking
  • registration
  • other
  • Proof of payments for health care for the last 3 months, including:
  • health insurance premiums
  • co-payments
  • other out-of-pocket expenses
  • Copies of any court orders requiring payment and proof of such payments for the last 3 months, including:
  • cancelled checks
  • money orders
  • earning statements showing such deductions

IRS Instructions On How To Prepare a Collection Information Statement Form 433-A

www.irs.gov