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Form-433A-Full (Wage-Earners-Only) - Testing

Step 1 of 4

25%
Note: Include attachments if additional space is needed to respond completely to any question.

Section-1: Personal And Household Information

MM slash DD slash YYYY
MM slash DD slash YYYY
Address
Be careful with spellings | Don't include the word County. Like For Orange County, just type "Orange"
Married and lived in
Mailing Address (If Different than above)
Be careful with spellings | Don't include the word County. Like For Orange County, just type "Orange"

Provide Information about your spouse.

MM slash DD slash YYYY

Provide information for all other persons in the household or claimed as a dependent.

Dependents
Name
Age
Relationship
Claimed as Dependent in Form 1040? Y/N
Contributes to Household Income? Y/N
Possesses a Driving License? Y/N
 
Click symbol at the end of last field to add details of another dependent.

Section-2: Employment Information for wage earners

Complete this section if you or your spouce are wage earners and receive a Form W-2. If you or your spouce have self-employment income (that is you file a Schedule C, E, F, etc.) instead of, or in addition to wage income, you must also complete Business Information in Sections 4, 5, and 6.

Your Employer's Details


Years / Months
Street, City, State, Zip code

Your Spouse's Employer's Details


Years / Months
Street, City, State, Zip code

Section-3: Personal Asset Information

Use the most current statement for each type of account, such as checking, savings, money market and online accounts, stored value cards (such as a payroll card from an employer), investment, retirement accounts (IRAs, Keogh, 401(k) plans, stocks, bonds, mutual funds, certificates of deposit) and virtual currency (such as Bitcoin, Ripple, Ethereum, etc.), life insurance policies that have a cash value, and safe deposit boxes including those located in foreign countries or jurisdictions. Asset value is subject to adjustment by IRS based on individual circumstances. Enter the total amount available for each of the following (if additional space is needed include attachments).

Round to the nearest dollar. Do not enter a negative number. If any line item is a negative number, enter "0".

Cash and Investments


We have provided space for limited Investment Accounts below. Use just the ones that you need and leave unwanted empty. However, if you have more to declare, get a total of all sources and put in the "Total from Other Accounts mentioned in the Attachments" field and attach details with this form on a separate paper.

Total of Other Bank Accounts
mentioned in Attachment


Total (Acc1 + Acc2 + Acc3 - 1000 )




Virtual Currency
 

Total from Other Accounts mentioned in the Attachments. [current market value minus loan balance(s)]


Total



Total from Other Accounts mentioned in the Attachments. [current market value X .8 minus loan balance(s)]


Total


Cash value of Life Insurance Policies


Total


Real Estate (enter information about any house, condo, co-op, time share, etc. that you own or are buying including any assets owned by your spouse if you live in a community property state)


Is your real property currently for sale or do you anticipate selling your real property to fund the offer amount

(Also indicate if personal residence, rental property, vacant, etc.)
MM slash DD slash YYYY
MM slash DD slash YYYY

(Also indicate if personal residence, rental property, vacant, etc.)
MM slash DD slash YYYY
MM slash DD slash YYYY


Total value of other property(s) from attachment [current market value X .8 minus any loan balance(s)]


Total


Vehicles (enter information about any cars, boats, motorcycles, etc. that you own or lease)


MM slash DD slash YYYY
Purchased On
MM slash DD slash YYYY
(if the vehicle is leased, enter 0 as the total value)

Subtract $3,450 from line V-1


MM slash DD slash YYYY
Purchased On
MM slash DD slash YYYY
(if the vehicle is leased, enter 0 as the total value)
Husband/Wife Filing Together?

If you are filing a joint offer, subtract $3,450 from V-2
If you are not filing a joint offer, enter the amount from line (6c)


Total value of any other vehicles (please provide detail in attachment) [current market value X .8 minus any loan balance(s)]


Total


Other valuable items (artwork, collections, jewelry, items of value in safe deposit boxes, interest in a company or business that is not publicly traded, etc.)


(if the vehicle is leased, enter 0 as the total value)

Value of remaining furniture and personal effects (not listed above)

(if the vehicle is leased, enter 0 as the total value)

Total value of any other valuable items (please provide detail in attachment) [current market value X .8 minus any loan balance(s)]


Total - Add lines (7a) through (7c) minus IRS deduction of $10,090


Total - Whole Section 3


Section 7: Monthly Household Income and Expense Information

Enter your household's gross monthly income. Gross monthly income includes wages, social security, pension, unemployment, and other income. Examples of other income include but are not limited to: agricultural subsidies, gambling income, oil credits, rent subsidies, Uber & Lyft driver income, and Airbnb rentals, etc. The information below is for yourself, your spouse, and anyone else who contributes to your household's income. The entire household includes spouse, non-liable spouse, significant other, children, and others who contribute to the household. This is necessary for the IRS to accurately evaluate your offer.


Monthly Household Income

Note: Entire household income should also include income that is considered not taxable and may not be included on your tax return.

e.g. Unemployment

Total Primary Tax Payer's Income =


Spouse's Income

e.g. Unemployment

Total Spouse's Income =

Additional sources of income used to support the household, e.g., non-liable spouse, or anyone else who may contribute to the household income, etc.

Interest, dividends, and royalties

Distributions (e.g., income from partnerships, sub-S Corporations, etc.)

Net rental income

Net business income (if any)

Child support received

Alimony received

Total Household Income

Monthly Household Expenses

Enter your average monthly expenses.
Note: For expenses claimed in boxes (39) and (45) only, you should list the full amount of the allowable standard even if the actual amount you pay is less. For the other boxes input your actual expenses. You may find the allowable standards at

http://www.irs.gov/Businesses/Small-Businesses-&-Self-Employed/Collection-Financial-Standards.

Food, clothing and miscellaneous

!

Housing and utilities

Home Insurance, Maintenance, Dues, Fees and Utilities (including electricity, gas, other fuels, trash collection, water, cable television and internet, telephone, and cell phone)
Mortgage + Property Taxes
!

No of Vehicles You Own.
Max 2 Allowed by IRS

Please enter a number less than or equal to 2.

Vehicle Loan and/or Lease Payment(s)
For Max 2 Cars

!

Vehicle operating costs (e.g., average monthly cost of maintenance, repairs, insurance, fuel, registrations, licenses, inspections, parking, tolls, etc.). A reasonable estimate of these expenses may be used

For Up to Max 2 Cars

Public transportation costs (e.g., average monthly cost of fares for mass transit such as bus, train, ferry, taxi, etc.). A reasonable estimate of these expenses may be used

!

Health insurance premiums

 

Out-of-pocket health care costs (e.g. average monthly cost of prescription drugs, medical services, and medical supplies like eyeglasses, hearing aids, etc.)

!

Court-ordered payments (e.g., monthly cost of any alimony, child support, etc.)

 

Child/dependent care payments (e.g., daycare, etc.)

 

Life Insurance

Life Insurance Total Policy Amount
Total of Life Insurance Premiums:
 

Current monthly taxes(e.g., monthly cost of federal, state, and local tax, personal property tax, etc.)

 

Secured debts/Other(e.g., any loan where you pledged an asset as collateral not previously listed, government guaranteed student loan, employer required retirement or dues)

 

Enter the Amount of your Monthly Delinquent State and/or Local Tax Payment(s)

 

Total Household Expenses

 

Remaining Monthly Income

 

Section 8: Calculate Your Minimum Offer Amount

The next steps calculate your minimum offer amount. The amount of time you take to pay your offer in full will affect your minimum offer amount. Paying over a shorter period of time will result in a smaller minimum offer amount.

Note: The multipliers below (12 and 24) and the calculated offer amount (which included the amount(s) allowed for vehicles and bank accounts) do not apply if the IRS determines you have the ability to pay your tax debt in full within the legal period to collect.

If you will pay your offer in 5 or fewer payments within 5 months or less, multiply "Remaining Monthly Income" (Box F) by 12 to get "Future Remaining Income" (Box G). Do not enter a number less than $0.

X 12 =


If you will pay your offer in 6 to 24 months, multiply "Remaining Monthly Income" (Box F) by 24 to get "Future Remaining Income" (Box H). Do not enter a number less than $0.


X 24 =


Determine your minimum offer amount by adding the total available assets from Box A and Box B (if applicable) to the amount in either Box G or Box H.


Your offer must be more than zero ($0). Do not leave blank. Use whole dollars only.
Your offer must be more than zero ($0). Do not leave blank. Use whole dollars only.

If you cannot pay the Offer Amount shown above due to special circumstances, explain on the Form 656, Offer in Compromise, Section 3, Reason for Offer. You must offer an amount more than $0.

Section 9: Other Information

Additional information IRS needs to consider settlement of your tax debt. If you or your business are currently in a bankruptcy proceeding, you are not eligible to apply for an offer.

Are you a party to or involved in litigation (if yes, answer the following)

MM slash DD slash YYYY

 

Have you filed bankruptcy in the past 7 years (if yes, answer the following)

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

 

In the past 10 years, have you lived outside of the U.S. for 6 months or longer (if yes, answer the following)

Dates lived abroad: From

MM slash DD slash YYYY

Lived To

MM slash DD slash YYYY

 

Are you or have you ever been party to any litigation involving the IRS/United States (including any tax litigation)

 

Are you the beneficiary of a trust, estate, or life insurance policy (if yes, answer the following)

MM slash DD slash YYYY

Are you a trustee, fiduciary, or contributor of a trust

 

Do you have a safe deposit box (business or personal) (if yes, answer the following)

 

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)

MM slash DD slash YYYY

 

Do you have any assets or own any real property outside the U.S.

 

Do you have any funds being held in trust by a third party

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National Standards: Out-of-Pocket Health Care

Out-of-pocket health care expenses include medical services, prescription drugs, and medical supplies (e.g. eyeglasses, contact lenses, etc.). Elective procedures such as plastic surgery or elective dental work are generally not allowed.

Taxpayers and their dependents are allowed the standard amount monthly on a per person basis, without questioning the amounts they actually spend.  If the amount claimed is more than the total allowed by the health care standards, the taxpayer must provide documentation to substantiate those expenses are necessary living expenses. Generally, the number of persons allowed should be the same as those allowed as dependents on the taxpayer’s most recent year income tax return.

The out-of-pocket health care standard amount is allowed in addition to the amount taxpayers pay for health insurance. For more information see here.

If you want to get your application approved, please don’t exceed the suggested upper limit. If you have to please submit supporting documents to prove why you have to.

Public Transportation

There is a single nationwide allowance for public transportation based on Bureau of Labor Statistics expenditure data for mass transit fares for a train, bus, taxi, ferry, etc. Taxpayers with no vehicle are allowed the standard amount monthly, per household, without questioning the amount actually spent.

If a taxpayer owns a vehicle and uses public transportation, expenses may be allowed for both, provided they are needed for the health and welfare of the taxpayer or family, or for the production of income. However, the expenses allowed would be actual expenses incurred for ownership costs, operating costs and public transportation, or the standard amounts, whichever is less.

If the amount claimed for Ownership Costs, Operating Costs or Public Transportation is more than the total allowed by the transportation standards, the taxpayer must provide documentation to substantiate those expenses are necessary living expenses.

If you want to get your application approved, please don’t exceed the suggested upper limit. If you have to please submit supporting documents to prove why you have to.

Ownership Costs

The ownership costs, shown in the table below, provide the monthly allowances for the lease or purchase of up to two automobiles. A single taxpayer is normally allowed one automobile. For each automobile, taxpayers will be allowed the lesser of:

  1. the monthly payment on the lease or car loan, or
  2. the ownership costs shown in the table here.

You can also see also This Page for more details.

If a taxpayer has no lease or car loan payment, the amount allowed for Ownership Costs will be $0.

If you want to get your application approved, please don’t exceed the suggested upper limit. If you have to please submit supporting documents to prove why you have to.

National Standards: Food, Clothing and Other Items

National Standards have been established for five necessary expenses: food, housekeeping supplies, apparel and services, personal care products and services, and miscellaneous.

The National Standard for Food, Clothing and Other Items includes an amount for miscellaneous expenses. This miscellaneous allowance is for expenses taxpayers may incur that are not included in any other allowable living expense items, or for any portion of expenses that exceed the Collection Financial Standards and are not allowed under a deviation.

The standards are derived from the Bureau of Labor Statistics Consumer Expenditure Survey. The survey collects information from the Nation’s households and families on their buying habits (expenditures), income and household characteristics.

Additional information and the standard amounts are available on our National Standards for Food, Clothing and Other Items web page. You may also download the standardsPDF in PDF format for printing.

If you want to get your application approved, please don’t exceed the suggested upper limit. If you have to please submit supporting documents to prove why you have to.

Local Standards: Housing and Utilities

The housing and utilities standards are derived from U.S. Census Bureau, American Community Survey and BLS data, and are provided by state down to the county level. The standard for a particular county and family size includes both housing and utilities allowed for a taxpayer’s primary place of residence. Housing and utilities standards are also provided for Puerto Rico.

Housing and Utilities standards include mortgage or rent, property taxes, interest, insurance, maintenance, repairs, gas, electric, water, heating oil, garbage collection, residential telephone service, cell phone service, cable television, and Internet service. The tables include five categories for one, two, three, four, and five or more persons in a household.

Additional information and the standard amounts are available by state or territory on our Housing and Utilities Standards web page. You may also download the standardsPDF in PDF format for printing. Please be advised that the housing and utilities document is 108 printed pages.

If you want to get your application approved, please don’t exceed the suggested upper limit. If you have to please submit supporting documents to prove why you have to.

Start Here! Eligibility Check 1

Your Source of Income?

Approx. how much do you owe IRS? $

Are you in an Open Bankruptcy proceeding?

Are you in an Open Bankruptcy proceeding?(Required)

Have you filed all required federal tax returns?

Have you filed all required federal tax returns?(Required)

Have you made all required estimated tax payments?

Have you made all required estimated tax payments?(Required)

If you are self-employed and have employees, have you submitted all required federal tax deposits?

If you are self-employed and have employees, have you submitted all required federal tax deposits?(Required)
This field is for validation purposes and should be left unchanged.