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Checklist of Attachments Required for IRS Form 433-A

(check space for each paragraph or put "N/A" for "not applicable")

  1. ___ Copy of your last Form 1040, income tax return, with all schedules and attachments.
  2. ___ Proof of self-employment income for the past 3 months (e.g., invoices, commissions, sales records, income statement).
  3. ___ Proof of gross earnings and deductions for the past 3 months from each employer (e.g., pay stubs, earnings statements). If year-to-date information is available, send only 1 such statement as long as a minimum of 3 months is represented.
  4. ___ Proof of pension/social security/other income for the past 3 months from each payor, including any statements showing deductions. If year-to-date information is available, send only 1 such statement as long as a minimum of 3 months is represented.
  5. ___ Current bank statements (checking, savings, money market, and brokerage accounts) for the past 3 months for all accounts.
  6. ___ Statement from life insurance companies for each policy that includes type (e.g., term, whole life, universal) and cash/loan value amounts. If currently borrowed against, include loan amount and date of loan.
  7. ___ Current statement from lender/lessor with monthly car payment amount and current balance of the loan for each vehicle purchased or leased.
  8. ___ Current statement from lender with monthly payment amount and current balance for each piece of real estate owned.
  9. ___ Proof of all current expenses that you paid for the past 3 months, including rent, utilities, insurance, property taxes, etc.
  10. ___ Proof of all non-business transportation expenses (e.g., car payments, lease payments, fuel, oil, insurance, parking, registration).
  11. ___ Proof of payments for health care, including health insurance premiums, co-payments, prescriptions, monthly payments for prior medical bills and other out-of-pocket expenses, for the past 3 months.
  12. ___ Copies of any court order requiring payment and proof of such payments (e.g., cancelled checks, money orders, earning statements showing such deductions) for the past 3 months.
  13. ___ Copy of deed or contract for each real property owned.
  14. ___ Copy of deed of trust or mortgage, and note for each real property owned.
  15. ___ Copy of child support pursuant to Court order or voluntary agreement and proof of such payments (e.g., cancelled checks, money orders, earning statements showing such deductions) for the past 3 months.
  16. ___ Copy of garnishment or attachment order by court.
  17. ___ Copy of judgment(s)