Enlarge image
Form 433-A
(May 2020) Collection Information Statement for Wage
Department of the Treasury Earners and Self-Employed Individuals
Internal Revenue Service
Wage Earners Complete Sections 1, 2, 3, 4, and 5 including the signature line on page 4. Answer all questions or write N/A if the question is not applicable.
Self-Employed Individuals Complete Sections 1, 3, 4, 5, 6 and 7 and the signature line on page 4. Answer all questions or write N/A if the question is not applicable.
For Additional Information, refer to Publication 1854, "How To Prepare a Collection Information Statement."
Include attachments if additional space is needed to respond completely to any question.
Name on Internal Revenue Service (IRS) Account SSN or ITIN on IRS Account Employer Identification Number EIN
Section 1: Personal Information
1a Full Name of Taxpayer and Spouse (if applicable) 1c Home Phone 1d Cell Phone
( ) ( )
1b Address (Street, City, State, ZIP code) (County of Residence) 1e Business Phone 1f Business Cell Phone
( ) ( )
2b Name, Age, and Relationship of persons in household or claimed as a
dependent(s)
2a Marital Status: Married Unmarried (Single, Divorced, Widowed)
SSN or ITIN Date of Birth (mmddyyyy) Driver's License Number and State
3a Taxpayer
3b Spouse
Section 2: Employment Information for Wage Earners
If you or your spouse have self-employment income instead of, or in addition to wage income, complete Business Information in Sections 6 and 7.
Taxpayer Spouse
4a Taxpayer's Employer Name 5a Spouse's Employer Name
4b Address (Street, City, State, and ZIP code) 5b Address (Street, City, State, and ZIP code)
4c Work Telephone Number 4d Does employer allow contact at work 5c Work Telephone Number 5d Does employer allow contact at work
( ) Yes No ( ) Yes No
4e How long with this employer 4f Occupation 5e How long with this employer 5f Occupation
(years) (months) (years) (months)
4g Number of withholding allowances 4h Pay Period: 5g Number of withholding allowances 5h Pay Period:
claimed on Form W-4 claimed on Form W-4
Weekly Bi-weekly Weekly Bi-weekly
Monthly Other Monthly Other
Section 3: Other Financial Information (Attach copies of applicable documentation)
6 Are you a party to a lawsuit (If yes, answer the following) Yes No
Location of Filing Represented by Docket/Case No.
Plaintiff Defendant
Amount of Suit Possible Completion Date (mmddyyyy) Subject of Suit
$
7 Have you ever filed bankruptcy (If yes, answer the following) Yes No
Date Filed (mmddyyyy) Date Dismissed (mmddyyyy) Date Discharged (mmddyyyy) Petition No. Location Filed
8 In the past 10 years, have you lived outside of the U.S for 6 months or longer (If yes, answer the following) Yes No
Dates lived abroad: from (mmddyyyy) To (mmddyyyy)
9a Are you the beneficiary of a trust, estate, or life insurance policy (If yes, answer the following) Yes No
Place where recorded: EIN:
Name of the trust, estate, or policy Anticipated amount to be received When will the amount be received
$
9b Are you a trustee, fiduciary, or contributor of a trust Yes No
Name of the trust: EIN:
10 Do you have a safe deposit box (business or personal) (If yes, answer the following) Yes No
Location (Name, address and box number(s)) Contents Value
$
11 In the past 10 years, have you transferred any assets for less than their full value (If yes, answer the following) Yes No
List Asset(s) Value at Time of Transfer Date Transferred (mmddyyyy) To Whom or Where was it Transferred
$
Catalog Number 20312N www.irs.gov Form 433-A (Rev. 5-2020)
