Form 433-Oic - Financial Statement For Wage Earners And Self-Employed
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4Form
IRS
Department of the Treasury
Internal Revenue Service
433-OIC
For use by individuals who owe income taxes totaling $50,000 or less.
Financial Statement for Wage Earners and Self-Employed
Complete all entry spaces. Important! Write “N/A” (not applicable) in spaces that do not apply.
Please Note: If you are in bankruptcy or not current in filing all tax returns due, your offer cannot be considered.
Section 1
2. Home
Best Time To Call:
1. Full Name(s)
Telephone
am
pm
(
)
Personal
Street Address
Information
3. Marital Status:
City
State
Zip
Married
Separated
County of Residence
Unmarried (single, divorced, widowed)
How long at this address
4. Your Social Security No.
4a. Your Date of Birth (mm/dd/yyyy)
5. Spouse’s Social Security No.
5a. Spouse’s Date of Birth (mm/dd/yyyy)
6.
Own Home
Rent
Other (specify, i.e. share rent, live with relative)
7. List the dependents you can claim on your tax return: (Attach sheet if more space is needed.)
First Name
Relationship
Age
Does this person
First Name
Relationship
Age
Does this person
live with you?
live with you?
No
Yes
No
Yes
No
Yes
No
Yes
Section 2
8. Are you or your spouse self-employed or do you or your
Employer Identification No., if available :
spouse operate your own business?
Do you have employees?
No
Yes
Your
No
Yes If yes, provide the following information:
Do you have accounts receivable?
No
Yes
Business
Information
Name of Business
If yes, please provide the total amount of accounts receivable
Street Address
that is due and payable: $
City
State
Zip
(Attach sheet if more space is needed.)
Section 3
9. Your Employer
10. Spouse’s Employer
Employment
Street Address
Street Address
Information
City
State
Zip
City
State
Zip
Work telephone no. (
)
Work telephone no. (
)
Can you be contacted at work?
No
Yes
Can you be contacted at work?
No
Yes
9a. How long with this employer
10a. How long with this employer
9b. Occupation
10b. Occupation
Section 4
11a. Checking Accounts. List all checking accounts.
Banking,
Name of Bank, Savings & Loan,
3-Month Deposit
Investment,
Type of Account
Credit Union or Financial Institution
Account No.
Average
(see below)
and Cash
Information
Checking
$
Checking
Checking
0.00
11a. Total 3-Month Deposit Avg.
$
To get your 3-month deposit average for each checking account:
- Add the deposits for the last 3 months. For example: $1,406.52 + $1,396.88 + $2,041.02 = $4,844.42
- Divide the total by 3 to get the average. For example: $4,844.42 3 = $1,614.81
Each checking account must be averaged separately.
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Section 4 continued on next page
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