0626 Form 433-A (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f433a.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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Form

(June 2026) Department of the Treasury Internal Revenue Service

Wage Earners Complete Sections 1, 2, 3, 4, and 5 including the signature line on page 6. 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 including the signature line on page 6. 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.

2c Provide information for all other persons in the household or claimed as a dependent.

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.

Explain (use attachment if needed)

Form 433-A (Rev. 6-2026) Page 2

Country of dual citizenship: 9a Are you currently incarcerated (If yes, provide your inmate number) Yes No Inmate number:

9b 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

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

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.).

Account Balance

As of

Type of Account

Full Name & Address (Street, City, State, ZIP code and

Country) of Bank, Savings & Loan, Credit Union, or

Account Number

Financial Institution

mmddyyyy 13a

$ 13b

$ 13c

$ 13d

$

13e Total Cash (Add lines 13a, 13b, 13c, 13d 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.

Loan Balance (if applicable)

As of

mmddyyyy

Equity Value minus Loan

Type of Investment or Financial Interest

Full Name & Address Current Value (Street, City, State, ZIP code and Country) of Company

14a

Phone $ $ $ 14b

Phone $ $ $ 14c

Phone $ $ $ 14d

Phone $ $ $

Catalog Number 20312N www.irs.gov Form 433-A (Rev. 6-2026)

Form 433-A (Rev. 6-2026) Page 3

Section 4: Personal Asset Information for all Individuals (Foreign and Domestic) (Continued)

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.

15 List the name(s) of individuals who have access to the private key(s) and/or digital wallets

Digital Asset Amount

Email Address Used to Set-up With the Digital Assets such as

Virtual Currency Exchange or

DCE

and Value in US

dollars as of

mmddyyyy

(e.g., 1 Bitcoins $38,000.00 USD)

Type of Digital Asset

Name of Digital Asset such as Virtual Currency Wallet, Exchange

or Digital Currency Exchange

(DCE)

Location(s) of Digital Assets

(Mobile Wallet, Online, and/or

External Hardware storage)

15a

$ 15b

$ 15c

$ 15d

$

15e Total Equity (Add lines 15a, 15b, 15c and amounts from any attachments) $

AVAILABLE CREDIT Include all lines of credit and bank issued credit cards.

Available Credit

As of

mmddyyyy

Full Name & Address Credit Limit (Street, City, State, ZIP code and Country) of Credit Institution

Amount Owed

As of

mmddyyyy

16a

Acct. No $ $ $ 16b

Acct. No $ $ $ 16c

Acct. No $ $ $ 16d

Acct. No $ $ $

16e Total Available Credit (Add lines 16a, 16b, 16c, 16d and amounts from any attachments) $

17 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.

17a Name and Address of Insurance Company(ies):

17b Policy Number(s)

17c Owner of Policy

17d Current Cash Value $

17e Outstanding Loan Balance $

$

$

$

$

17f Total Available Cash (Subtract amounts on line 17e from line 17d and include amounts from any attachments) $

Catalog Number 20312N www.irs.gov Form 433-A (Rev. 6-2026)

Form 433-A (Rev. 6-2026) Page 4

Section 4: Personal Asset Information for all Individuals (Foreign and Domestic) (Continued)

REAL PROPERTY Enter information about any house, condo, co-op, time share, etc., that you own, are purchasing, or in which you hold an interest, including through a life estate. If you live in a community property state, also include real property in which you may have a community-property interest under applicable state law. Identify all title holders and how title is held.

Location (street, city, state, ZIP code, county and country) Lender/Contract Holder Name, Address (street, city, state, ZIP code), and Phone

Phone 18b Property Description

$ $ $ $

Name of all title holders and how title is held (joint tenancy, etc.)

Location (street, city, state, ZIP code, county and country) Lender/Contract Holder Name, Address (street, city, state, ZIP code), and Phone

Phone

18c Property Description

$ $ $ $

Name of all title holders and how title is held (joint tenancy, etc.)

Location (street, city, state, ZIP code, county and country)

Lender/Contract Holder Name, Address (street, city, state, ZIP code), and Phone

Phone

18d Total Equity (Add lines 18a, 18b, 18c and amounts from any attachments) $ PERSONAL VEHICLES LEASED AND PURCHASED Include boats, RVs, motorcycles, all-terrain and off-road vehicles, trailers, etc.

Current Fair Market Value

(FMV)

Description (Year, Mileage, Make/Model, Tag Number, Vehicle Identification Number)

19a Year Make/Model

Mileage License/Tag Number

Vehicle Identification Number

19b Year Make/Model

Mileage License/Tag Number

Vehicle Identification Number

Purchase/ Lease Date (mmddyyyy)

Phone

$ $ $ $ Lender/Lessor Name, Address (street, city, state, ZIP code and country), and Phone

Phone

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

$

$

$

19c Year Make/Model $ $ $ $

Mileage License/Tag Number

Vehicle Identification Number

Lender/Lessor Name, Address (street, city, state, ZIP code and country), and Phone

Phone

19d Total Equity (Add lines 19a, 19b, 19c and amounts from any attachments) $

Catalog Number 20312N www.irs.gov Form 433-A (Rev. 6-2026)

Form 433-A (Rev. 6-2026) Page 5

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.

Catalog Number 20312N www.irs.gov Form 433-A (Rev. 6-2026)

Form 433-A (Rev. 6-2026) Page 6 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.)

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 x 4.3 = $1,831.33 If paid biweekly (every 2 weeks) - multiply biweekly gross wages by 2.17. Example: $972.45 x 2.17 = $2,110.22 If paid semimonthly (twice each month) - multiply semimonthly gross wages by 2. Example: $856.23 x 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 8, line 90 . 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. 6-2026)

Form 433-A (Rev. 6-2026) Page 7 Sections 6 and 7 must be completed only if you are SELF-EMPLOYED. Section 6: Business Information (Foreign and Domestic)

52 Is the business a sole proprietorship (filing Schedule C) Yes, Continue with Sections 6 and 7. No, Complete Form 433-B. All other business entities, including limited liability companies, partnerships or corporations, must complete Form 433-B.

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

Payment Processor Account Name & Address (Street, City, State, ZIP code, and Country)

Number

62a

62b CREDIT CARDS ACCEPTED BY THE BUSINESS

Credit Card Merchant Account Number Issuing Bank Name & Address (Street, City, State, ZIP code, and Country)

63a

63b

63c

64 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.

Full name & Address (Street, City, State, ZIP code, and Country) Type of Account Account Number

of Bank, Savings & Loan, Credit Union or Financial Institution.

Account Balance

As of

mmddyyyy

65a $

65b $

65c Total Cash in Banks (Add lines 65a, 65b 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.

Date Due (mmddyyyy)

Accounts/Notes Receivable & Address (Street, City, State, ZIP code, and Country)

Status (e.g., age,

factored, other)

Invoice Number or Government

Amount Due Grant or Contract Number

66a $

66b $

66c $

66d $

66e $

66f Total Outstanding Balance (Add lines 66a through 66e and amounts from any attachments) $

Catalog Number 20312N www.irs.gov Form 433-A (Rev. 6-2026)

Form 433-A (Rev. 6-2026) Page 8

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.

Location (street, city, state, ZIP code, and country) Lender/Lessor/Landlord Name, Address (street, city, state, ZIP code), and Phone

Phone

67b Property Description $ $ $ $ Name of all title holders

Location (street, city, state, ZIP code, and country) Lender/Lessor/Landlord Name, Address (street, city, state, ZIP code), and Phone

Phone

67c Total Equity (Add lines 67a, 67b and amounts from any attachments) $ Section 7 should be completed only if you are SELF-EMPLOYED

Section 7: Sole Proprietorship Information (lines 68 through 88 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.

Enter the monthly net income amount from line 90 on line 24, section 5. If line 90 is a loss, enter "0" on line 24, section 5.

Self-employed taxpayers must return to page 6 to sign the certification. 1 Materials Purchased: Materials are items directly related to the 5 Current Taxes: production of a product or service. 2 Inventory Purchased: Goods bought for resale. taxes. 3 Supplies: Supplies are items used in the business that are 6 Net Business Income: consumed or used up within one year. This could be the cost of books, office supplies, professional equipment, etc.

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

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

IRS USE ONLY (Notes)

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 6). 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.

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. 6-2026)