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Department of the Treasury
Internal Revenue Service

Form 433-A
(July 2022)
Collection Information Statement for Wage Earners and Self-Employed Individuals

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.

Section 1: Personal Information

1a Full Name of Taxpayer and Spouse (if applicable) ----
1b Address (street, city, state, ZIP code and country) ----
1c County of Residence ----
1d Home Phone ----
1e Cell Phone ----
1f Work Phone ----
2a Marital Status:
-- Married
-- Unmarried (Single, Divorced, Widowed)
2b
Taxpayer
SSN or ITIN ----
Date of Birth (mmddyyyy) ----
Spouse
SSN or ITIN ----
Date of Birth (mmddyyyy) ----
2c Provide information on all other persons in household or claimed as dependents three blank lines shown in print
Name ----
Age ----
Relationship ----
3a Do you or your spouse have any outside business interests? Include any interest in an LLC, LLP, corporation, partnership, etc.
-- Yes (percentage of ownership ---- %)
Title ----
-- No
3b Business name ----
3c Type of business (select one)
-- Partnership
-- LLC
-- Corporation
-- Other ----

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

4a Taxpayer's Employer Name ----
4b Address (street, city, state, ZIP code and country) ----
4c Work Telephone Number ----
4d Does employer allow contact at work
-- Yes
-- No
4e How long with this employer ---- (years) ---- (months)
4f Occupation ----
4g Number claimed as a dependent on your Form 1040 ----
4h Pay Period:
-- Weekly
-- Bi-weekly
-- Monthly
-- Other

Spouse

5a Spouse's Employer Name ----
5b Address (street, city, state, ZIP code and country) ----
5c Work Telephone Number ----
5d Does employer allow contact at work
-- Yes
-- No
5e How long with this employer ---- (years) ---- (months)
5f Occupation ----
5g Number claimed as a dependent on your Form 1040 ----
5h Pay Period:
-- Weekly
-- Bi-weekly
-- 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
-- Plaintiff
-- Defendant
Location of Filing ----
Represented by ----
Docket/Case No. ----
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 including those located in foreign countries or jurisdictions (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) including those located in foreign countries or jurisdictions (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 with a fair market value of more than $10,000 including real property, 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. 7-2022)

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Form 433-A (Rev. 7-2022)
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Section 4: Personal Asset Information for all Individuals (Foreign and Domestic). Include assets located in foreign countries or jurisdictions and add attachment(s) if additional space is needed to respond

12 CASH ON HAND Include cash that is not in a bank
Total Cash on Hand $ ----

PERSONAL BANK ACCOUNTS

Include all checking, online and mobile (e.g., PayPal etc.) accounts, money market accounts, savings accounts, and stored value cards (e.g., payroll cards, government benefit cards, etc.).

13a
Type of Account ----
Full Name & Address (Street, City, State, ZIP code and Country) of Bank, Savings & Loan, Credit Union, or Financial Institution ----
Account Number ----
Account Balance As of ---- mmddyyyy $ ----
13b
Type of Account ----
Full Name & Address (Street, City, State, ZIP code and Country) of Bank, Savings & Loan, Credit Union, or Financial Institution ----
Account Number ----
Account Balance As of ---- mmddyyyy $ ----

13c Total Cash (Add lines 13a, 13b, and amounts from any attachments) $ ----

INVESTMENTS

Include stocks, bonds, mutual funds, stock options, certificates of deposit, and retirement assets such as IRAs, Keogh, 401(k) plans and commodities (e.g., gold, silver, copper, etc.). Include all corporations, partnerships, limited liability companies, or other business entities in which you are an officer, director, owner, member, or otherwise have a financial interest. 

14a
Type of Investment or Financial Interest ----
Full Name & Address (Street, City, State, ZIP code and Country) of Company ----
Phone ----
Current Value $ ----
Loan Balance (if applicable) As of ---- mmddyyyy $ ----
Equity Value minus Loan ----
14b
Type of Investment or Financial Interest ----
Full Name & Address (Street, City, State, ZIP code and Country) of Company ----
Phone ----
Current Value $ ----
Loan Balance (if applicable) As of ---- mmddyyyy $ ----
Equity Value minus Loan ----

DIGITAL ASSETS

List all digital assets such as virtual currency (cryptocurrency), non-fungible token (NFT), and smart contracts you own or in which you have a financial interest (e.g., Bitcoin, Ethereum, Litecoin, Ripple, etc.) If applicable, attach a statement with each virtual currency's public key.

14c List the name(s) of individuals who have access to the private key(s) and/or digital wallets ----
14d
Type of Digital Asset ----
Name of Digital Asset such as Virtual Currency Wallet, Exchange or Digital Currency Exchange (DCE) ----
Email Address Used to Set-up With the Digital Assets such as Virtual Currency Exchange or DCE ----
Location(s) of Digital Assets (Mobile Wallet, Online, and/or External Hardware storage) ----
Digital Asset Amount and Value in US dollars as of today (e.g., 1 Bitcoins $38,000.00 USD) $ ----
14e
Type of Digital Asset ----
Name of Digital Asset such as Virtual Currency Wallet, Exchange or Digital Currency Exchange (DCE) ----
Email Address Used to Set-up With the Digital Assets such as Virtual Currency Exchange or DCE ----
Location(s) of Digital Assets (Mobile Wallet, Online, and/or External Hardware storage) ----
Digital Asset Amount and Value in US dollars as of today (e.g., 1 Bitcoins $38,000.00 USD) $ ----

14f Total Equity (Add lines 14a, 14b, 14d and 14e. Also include any amounts from any attachments to your total equity) $ ----

AVAILABLE CREDIT

Include all lines of credit and bank issued credit cards.

15a
Full Name & Address (Street, City, State, ZIP code and Country) of Credit Institution ----
Acct. No ----
Credit Limit $ ----
Amount Owed As of ---- mmddyyyy $ ----
Available Credit As of ---- mmddyyyy $ ----
15b
Full Name & Address (Street, City, State, ZIP code and Country) of Credit Institution ----
Acct. No ----
Credit Limit $ ----
Amount Owed As of ---- mmddyyyy $ ----
Available Credit As of ---- mmddyyyy $ ----
15c Total Available Credit (Add lines 15a, 15b and amounts from any attachments) ----
16a LIFE INSURANCE Do you own or have any interest in any life insurance policies with cash value -- Yes -- No If yes, complete blocks 16b through 16f for each policy.

There are three blank columns to be filled in for lines 16b-16f.

16b Name and Address of Insurance Company(ies): ----
16c Policy Number(s) ----
16d Owner of Policy ----
16e Current Cash Value $ ----
16f Outstanding Loan Balance $ ----
16g Total Available Cash (Subtract amounts on line 16f from line 16e and include amounts from any attachments) $ ----

Catalog Number 20312N
www.irs.gov
Form 433-A (Rev. 7-2022)

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Form 433-A (Rev. 7-2022)
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Section 4: Personal Asset Information for all Individuals (Foreign and Domestic) (Continued)

REAL PROPERTY

Include all real property owned or being purchased

17a Property Description ----
Purchase Date (mmddyyyy) ----
Current Fair Market Value (FMV) $ ----
Current Loan Balance $ ----
Amount of Monthly Payment $ ----
Date of Final Payment (mmddyyyy) ----
Equity FMV Minus Loan $ ----
Location (street, city, state, ZIP code, county and country) ----
Lender/Contract Holder Name, Address (street, city, state, ZIP code), and Phone ----
Phone ----
17b Property Description ----
Purchase Date (mmddyyyy) ----
Current Fair Market Value (FMV) $ ----
Current Loan Balance $ ----
Amount of Monthly Payment $ ----
Date of Final Payment (mmddyyyy) ----
Equity FMV Minus Loan $ ----
Location (street, city, state, ZIP code, county and country) ----
Lender/Contract Holder Name, Address (street, city, state, ZIP code), and Phone ----
Phone ----
17c Total Equity (Add lines 17a, 17b and amounts from any attachments) $ ----

PERSONAL VEHICLES LEASED AND PURCHASED

Include boats, RVs, motorcycles, all-terrain and off-road vehicles, trailers, etc.

18a
Description (Year, Mileage, Make/Model, Tag Number, Vehicle Identification Number)
Year ----
Make/Model ----
Mileage ----
License/Tag Number ----
Vehicle Identification Number ----
Purchase/Lease Date (mmddyyyy) ----
Current Fair Market Value (FMV) $ ----
Current Loan Balance $ ----
Amount of Monthly Payment $ ----
Date of Final Payment (mmddyyyy) ----
Equity FMV Minus Loan $ ----
Lender/Lessor Name, Address (street, city, state, ZIP code and country), and Phone ----
Phone ----
18b
Description (Year, Mileage, Make/Model, Tag Number, Vehicle Identification Number)
Year ----
Make/Model ----
Mileage ----
License/Tag Number ----
Vehicle Identification Number ----
Purchase/Lease Date (mmddyyyy) ----
Current Fair Market Value (FMV) $ ----
Current Loan Balance $ ----
Amount of Monthly Payment $ ----
Date of Final Payment (mmddyyyy) ----
Equity FMV Minus Loan $ ----
Lender/Lessor Name, Address (street, city, state, ZIP code and country), and Phone ----
Phone ----
18c Total Equity (Add lines 18a, 18b and amounts from any attachments) $ ----

PERSONAL ASSETS

Include all furniture, personal effects, artwork, jewelry, collections (coins, guns, etc.), antiques or other assets. Include intangible assets such as licenses, domain names, patents, copyrights, mining claims, etc.

19a Property Description ----
Purchase/Lease Date (mmddyyyy) ----
Current Fair Market Value (FMV) $ ----
Current Loan Balance $ ----
Amount of Monthly Payment $ ----
Date of Final Payment (mmddyyyy) ----
Equity FMV Minus Loan $ ----
Location (street, city, state, ZIP code, county and country) ----
Lender/Lessor Name, Address (street, city, state, ZIP code), and Phone ----
Phone ----
19b Property Description ----
Purchase/Lease Date (mmddyyyy) ----
Current Fair Market Value (FMV) $ ----
Current Loan Balance $ ----
Amount of Monthly Payment $ ----
Date of Final Payment (mmddyyyy) ----
Equity FMV Minus Loan $ ----
Location (street, city, state, ZIP code, county and country) ----
Lender/Lessor Name, Address (street, city, state, ZIP code), and Phone ----
Phone ----
19c Total Equity (Add lines 19a, 19b and amounts from any attachments) $ ----

Catalog Number 20312N
www.irs.gov
Form 433-A (Rev. 7-2022)

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Form 433-A (Rev. 7-2022)
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If you are self-employed, sections 6 and 7 must be completed before continuing.

Section 5: Monthly Income and Expenses (Foreign and Domestic) 

Monthly Income/Expense Statement (For additional information, refer to Publication 1854.)

Total Income (Amounts reported in U.S. dollars)

Source

20 Wages (Taxpayer)1
Gross Monthly $ ----
21 Wages (Spouse)1
Gross Monthly $ ----
22 Interest - Dividends
Gross Monthly $ ----
23 Net Business Income2
Gross Monthly $ ----
24 Net Rental Income3
Gross Monthly $ ----
25 Distributions (K-1, IRA, etc.)4
Gross Monthly $ ----
26 Pension (Taxpayer)
Gross Monthly $ ----
27 Pension (Spouse)
Gross Monthly $ ----
28 Social Security (Taxpayer) 
Gross Monthly $ ----
29 Social Security (Spouse)
Gross Monthly $ ----
30 Child Support
Gross Monthly $ ----
31 Alimony
Gross Monthly $ ----

Other Income (Specify below)5

32 ----
Gross Monthly $ ----
33 ----
Gross Monthly $ ----
34 Total Income (add lines 20-33)
Gross Monthly $ ----

Total Living Expenses (Amounts reported in U.S. dollars)

Expense Items6

35 Food, Clothing and Misc.7
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
36 Housing and Utilities8
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
37 Vehicle Ownership Costs9
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
38 Vehicle Operating Costs10
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
39 Public Transportation11
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
40 Health Insurance
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
41 Out of Pocket Health Care Costs12
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
42 Court Ordered Payments
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
43 Child/Dependent Care
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
44 Life Insurance
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
45 Current year taxes (Income/FICA)13
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
46 Secured Debts (Attach list)
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
47 Delinquent State or Local Taxes 
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
48 Other Expenses (Attach list)
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
49 Total Living Expenses (add lines 35-48)
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----
50 Net difference (Line 34 minus 49)
Actual Monthly $ ----
IRS USE ONLY Allowable Expenses ----

1 Wages, salaries, pensions, and social security: Enter gross monthly wages and/or salaries. Do not deduct tax withholding or allotments taken out of pay, such as insurance payments, credit union deductions, car payments, etc. To calculate the gross monthly wages and/or salaries:
If paid weekly - multiply weekly gross wages by 4.3. Example: $425.89×4.3=$1,831.33
If paid biweekly (every 2 weeks) - multiply biweekly gross wages by 2.17. Example: $972.45×2.17=$2,110.22
If paid semimonthly (twice each month) - multiply semimonthly gross wages by 2. Example: $856.23×2=$1,712.46
2 Net Income from Business: Enter monthly net business income. This is the amount earned after ordinary and necessary monthly business expenses are paid. This figure is the amount from page 6, line 89. If the net business income is a loss, enter "0". Do not enter a negative number. If this amount is more or less than previous years, attach an explanation. 
3 Net Rental Income: Enter monthly net rental income. This is the amount earned after ordinary and necessary monthly rental expenses are paid. Do not include deductions for depreciation or depletion. If the net rental income is a loss, enter "0." Do not enter a negative number.
4 Distributions: Enter the total distributions from partnerships and subchapter S corporations reported on Schedule K-1, and from limited liability companies reported on Form 1040, Schedule C, D or E. Enter total distributions from IRAs if not included under pension income.
5 Other Income: Include agricultural subsidies, unemployment compensation, gambling income, oil credits, rent subsidies, sharing economy income from providing on-demand work, services or goods (e.g., Uber, Lyft, AirBnB, VRBO) and income through digital platforms like an app or website (e.g., YouTube, TikTok), etc. Recurring capital gains from the sale of securities including cryptocurrency and non-fungible tokens.
6 Expenses not generally allowed: We generally do not allow tuition for private schools, public or private college expenses, charitable contributions, voluntary retirement contributions or payments on unsecured debts. However, we may allow the expenses if proven that they are necessary for the health and welfare of the individual or family or the production of income. See Publication 1854 for exceptions.
7 Food, Clothing and Miscellaneous: Total of food, clothing, housekeeping supplies, and personal care products for one month. The miscellaneous allowance is for expenses incurred that are not included in any other allowable living expense items. Examples are credit card payments, bank fees and charges, reading material, and school supplies.
8 Housing and Utilities: For principal residence: Total of rent or mortgage payment. Add the average monthly expenses for the following: property taxes, homeowner's or renter's insurance, maintenance, dues, fees, and utilities. Utilities include gas, electricity, water, fuel, oil, other fuels, trash collection, telephone, cell phone, cable television and internet services.
9 Vehicle Ownership Costs: Total of monthly lease or purchase/loan payments.
10 Vehicle Operating Costs: Total of maintenance, repairs, insurance, fuel, registrations, licenses, inspections, parking, and tolls for one month.
11 Public Transportation: Total of monthly fares for mass transit (e.g., bus, train, ferry, taxi, etc.)
12 Out of Pocket Health Care Costs: Monthly total of medical services, prescription drugs and medical supplies (e.g., eyeglasses, hearing aids, etc.)
13 Current Year Taxes: Include state and Federal taxes withheld from salary or wages, or paid as estimated taxes.
Certification: Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities, and other information is true, correct, and complete.

Taxpayer's Signature ----
Spouse's signature ----
Date ----

After we review the completed Form 433-A, you may be asked to provide verification for the assets, encumbrances, income and expenses reported. Documentation may include previously filed income tax returns, pay statements, self-employment records, bank and investment statements, loan statements, bills or statements for recurring expenses, etc.

IRS USE ONLY (Notes) ----

Catalog Number 20312N
www.irs.gov
Form 433-A (Rev. 7-2022)

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Form 433-A (Rev. 7-2022)
Page 5

Sections 6 and 7 must be completed only if you are SELF-EMPLOYED.

Section 6: Business Information (Foreign and Domestic)

51 Is the business a sole proprietorship (filing Schedule C) All other business entities, including limited liability companies, partnerships or corporations, must complete Form 433-B.
-- Yes, Continue with Sections 6 and 7.
-- No, Complete Form 433-B.
52a Business Name & Address (if different than 1b) ----
52b Business Telephone Number ----
53 Employer Identification Number ----
54 Type of Business ----
55 Is the business a Federal Contractor
-- Yes
-- No
56 Business Website (web address) ----
57 Total Number of Employees ----
58 Average Gross Monthly Payroll ----
59 Frequency of Tax Deposits ----
60 Does the business engage in e-Commerce (Internet sales) If yes, complete lines 61a and 61b
-- Yes
-- No

PAYMENT PROCESSOR

(e.g., PayPal, Authorize.net, Google Checkout, BitPay, Crypto.com, etc.) Include virtual currency wallet, exchange or digital currency exchange.

61a
Name & Address (Street, City, State, ZIP code, and Country) ----
Payment Processor Account Number ----
61b
Name & Address (Street, City, State, ZIP code, and Country) ----
Payment Processor Account Number ----

CREDIT CARDS ACCEPTED BY THE BUSINESS

62a
Credit Card ----
Merchant Account Number ----
Issuing Bank Name & Address (Street, City, State, ZIP code, and Country) ----
62b
Credit Card ----
Merchant Account Number ----
Issuing Bank Name & Address (Street, City, State, ZIP code, and Country) ----
62c
Credit Card ----
Merchant Account Number ----
Issuing Bank Name & Address (Street, City, State, ZIP code, and Country) ----
63 BUSINESS CASH ON HAND Include cash that is not in a bank.
Total Cash on Hand $ ----

BUSINESS BANK ACCOUNTS

Include checking accounts, online and mobile (e.g., PayPal) accounts, money market accounts, savings accounts, and stored value cards (e.g., payroll cards, government benefit cards, etc.). Report Personal Accounts in Section 4.

64a
Type of Account ----
Full name & Address (Street, City, State, ZIP code, and Country) of Bank, Savings & Loan, Credit Union or Financial Institution. ----
Account Number ----
Account Balance As of ---- mmddyyyy $ ----
64b
Type of Account ----
Full name & Address (Street, City, State, ZIP code, and Country) of Bank, Savings & Loan, Credit Union or Financial Institution. ----
Account Number ----
Account Balance As of ---- mmddyyyy $ ----
64c Total Cash in Banks (Add lines 64a, 64b and amounts from any attachments) $ ----

ACCOUNTS/NOTES RECEIVABLE

Include e-payment accounts receivable and factoring companies, and any bartering or online auction accounts. (List all contracts separately, including contracts awarded, but not started.) Include Federal, state and local government grants and contracts.

65a
Accounts/Notes Receivable & Address (Street, City, State, ZIP code, and Country) ----
Status (e.g., age, factored, other) ----
Date Due (mmddyyyy) ----
Invoice Number or Government Grant or Contract Number ----
Amount Due $ ----
65b
Accounts/Notes Receivable & Address (Street, City, State, ZIP code, and Country) ----
Status (e.g., age, factored, other) ----
Date Due (mmddyyyy) ----
Invoice Number or Government Grant or Contract Number ----
Amount Due $ ----
65c
Accounts/Notes Receivable & Address (Street, City, State, ZIP code, and Country) ----
Status (e.g., age, factored, other) ----
Date Due (mmddyyyy) ----
Invoice Number or Government Grant or Contract Number ----
Amount Due $ ----
65d
Accounts/Notes Receivable & Address (Street, City, State, ZIP code, and Country) ----
Status (e.g., age, factored, other) ----
Date Due (mmddyyyy) ----
Invoice Number or Government Grant or Contract Number ----
Amount Due $ ----
65e
Accounts/Notes Receivable & Address (Street, City, State, ZIP code, and Country) ----
Status (e.g., age, factored, other) ----
Date Due (mmddyyyy) ----
Invoice Number or Government Grant or Contract Number ----
Amount Due $ ----
65f Total Outstanding Balance (Add lines 65a through 65e and amounts from any attachments) $ ----

Catalog Number 20312N
www.irs.gov
Form 433-A (Rev. 7-2022)

<Page 6>

Form 433-A (Rev. 7-2022)
Page 6

BUSINESS ASSETS

Include all tools, books, machinery, equipment, inventory or other assets used in trade or business. Include a list and show the value of all intangible assets such as licenses, patents, domain names, copyrights, trademarks, mining claims, etc.

66a Property Description ----
Purchase/Lease Date (mmddyyyy) ----
Current Fair Market Value (FMV) $ ----
Current Loan Balance $ ----
Amount of Monthly Payment $ ----
Date of Final Payment (mmddyyyy) ----
Equity FMV Minus Loan $ ----
Location (street, city, state, ZIP code, and country) ----
Lender/Lessor/Landlord Name, Address (street, city, state, ZIP code), and Phone ----
Phone ----
66b Property Description ----
Purchase/Lease Date (mmddyyyy) ----
Current Fair Market Value (FMV) $ ----
Current Loan Balance $ ----
Amount of Monthly Payment $ ----
Date of Final Payment (mmddyyyy) ----
Equity FMV Minus Loan $ ----
Location (street, city, state, ZIP code, and country) ----
Lender/Lessor/Landlord Name, Address (street, city, state, ZIP code), and Phone ----
Phone ----
66c Total Equity (Add lines 66a, 66b and amounts from any attachments) $ ----

Section 7 should be completed only if you are SELF-EMPLOYED

Section 7: Sole Proprietorship Information (lines 67 through 87 should reconcile with business Profit and Loss Statement)

Accounting Method Used: 
-- Cash
-- Accrual

Use the prior 3, 6, 9 or 12 month period to determine your typical business income and expenses.

Income and Expenses during the period (mmddyyyy) ---- to (mmddyyyy) ----

Provide a breakdown below of your average monthly income and expenses, based on the period of time used above.

Total Monthly Business Income (Amounts reported in U.S. dollars)

Source

67 Gross Receipts
Gross Monthly $ ----
68 Gross Rental Income
Gross Monthly $ ----
69 Interest
Gross Monthly $ ----
70 Dividends
Gross Monthly $ ----
71 Cash Receipts not included in lines 67-70
Gross Monthly $ ----

Other Income (Specify below)

72 ----
Gross Monthly $ ----
73 ----
Gross Monthly $ ----
74 ----
Gross Monthly $ ----
75 ----
Gross Monthly $ ----
76 Total Income (Add lines 67 through 75)
Gross Monthly $ ----

Total Monthly Business Expenses (Amounts reported in U.S. dollars) (Use attachments as needed)

Expense Items

77 Materials Purchased1
Actual Monthly $ ----
78 Inventory Purchased2
Actual Monthly $ ----
79 Gross Wages & Salaries
Actual Monthly $ ----
80 Rent
Actual Monthly $ ----
81 Supplies3
Actual Monthly $ ----
82 Utilities/Telephone4
Actual Monthly $ ----
83 Vehicle Gasoline/Oil
Actual Monthly $ ----
84 Repairs & Maintenance
Actual Monthly $ ----
85 Insurance
Actual Monthly $ ----
86 Current Taxes5
Actual Monthly $ ----
87 Other Expenses, including installment payments (Specify)
Actual Monthly $ ----
88 Total Expenses (Add lines 77 through 87)
Actual Monthly $ ----
89 Net Business Income (Line 76 minus 88)6
Actual Monthly $ ----

Enter the monthly net income amount from line 89 on line 23, section 5. If line 89 is a loss, enter "0" on line 23, section 5. Self-employed taxpayers must return to page 4 to sign the certification.

1 Materials Purchased: Materials are items directly related to the production of a product or service.

2 Inventory Purchased: Goods bought for resale.

3 Supplies: Supplies are items used in the business that are consumed or used up within one year. This could be the cost of books, office supplies, professional equipment, etc.

4 Utilities/Telephone: Utilities include gas, electricity, water, oil, other fuels, trash collection, telephone, cell phone and business internet.

5 Current Taxes: Real estate, excise, franchise, occupational, personal property, sales and employer's portion of employment taxes.

6 Net Business Income: Net profit from Form 1040, Schedule C may be used if duplicated deductions are eliminated (e.g., expenses for business use of home already included in housing and utility expenses on page 4). Deductions for depreciation and depletion on Schedule C are not cash expenses and must be added back to the net income figure. In addition, interest cannot be deducted if it is already included in any other installment payments allowed.

IRS USE ONLY (Notes) ----

Privacy Act: The information requested on this Form is covered under Privacy Acts and Paperwork Reduction Notices which have already been provided to the taxpayer.

Catalog Number 20312N
www.irs.gov
Form 433-A (Rev. 7-2022)
 