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Form 433-A (OIC) Collection Information Statement for …

Department of the Treasury Internal Revenue Service Form 433-A (OIC) Collection Information Statement for Wage Earners and (Rev. May 2012). Self-Employed Individuals Use this form if you are An individual who owes income tax on a Form 1040, An individual who is personally responsible for a Individual Income Tax Return partnership liability An individual with a personal liability for Excise Tax An individual who is self-employed or has self-employment income. You are considered to be self-employed if you are in An individual responsible for a Trust Fund Recovery Penalty business for yourself, or carry on a trade or business.

policies that have a cash value, and safe deposit boxes. 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). If any line item is zero or less, enter "0". Do not enter negative numbers on this form.

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