Form 433-H (Rev. 4-2020)

Catalog Number 71232U www.irs.gov

Form

433-H (Rev. 4-2020)

Form 433-H

(April 2020)

Department of the Treasury - Internal Revenue Service

Installment Agreement Request and

Collection Information Statement

Use Form 433-H if you earn wages, you are requesting an installment agreement, and your liability is either greater than $50,000 or cannot be paid

within 72 months.

Tip If you can pay your liability within 72 months or less and owe $50,000 or less, you may be able to establish an installment agreement online, even if

you have not yet received a bill for your taxes. Go to IRS.gov to apply to pay online.

Caution Do not use this form if you can pay your balance in full within 120 days. Instead, call the number on your most recent notice. If you are in

bankruptcy or we have accepted your offer-in-compromise, see Bankruptcy or Offer-in-Compromise, in the instructions.

Name(s) and address

If address provided above is different than last return filed,

please check here

County of Residence

Your Social Security Number or Individual Taxpayer Identification Number

Your Spouse’s Social Security Number or Individual Taxpayer Identification Number

Your Telephone Numbers

Home:

Work:

Cell:

Spouse’s Telephone Numbers

Home:

Work:

Cell:

Enter the number of people in the household who can be claimed on this year’s tax return including you and your spouse. Under 65 65 and Over

Part 1 - INSTALLMENT AGREEMENT REQUEST Complete to request an installment agreement

1. Enter the total amount you owe as shown on your tax return(s) (or notices(s) Form Tax Period

If you have additional balances due that are not reflected on Line 1, list the total here

(even if they are included in an existing

installment agreement)

Form

Tax Period(s)

3. Add lines 1 & 2 and enter the result

4. Enter the amount of the payment you are making with this request (See instructions.)

5. Subtract line 4 from line 3 and enter the result

Enter the amount you can pay each month. Make your payments as large as possible to limit interest and penalty charges,

since these charges will continue to accrue until you pay in full.

(If you have an existing installment agreement, this amount should

represent your total proposed monthly payment amount for all your liabilities.)

If no payment amount is listed on line 6, a payment will

be determined for you by analyzing the information you provided on your financial statement.

7. Enter the date you want to make your payment each month. Do not enter a date later than the 28th

If you want to make your payments by direct debit from your checking account, see the instructions and fill in lines 8a and 8b. This is the most

convenient way to make your payments and it will ensure that they are made on time.

a. Routing number

b. Account number

I authorize the U.S. Treasury and its designated Financial Agent to initiate a monthly ACH debit (electronic withdrawal) entry to the financial institution

account indicated for payments of my federal taxes owed, and the financial institution to debit the entry to this account. This authorization is to

remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke payment, I must contact the

U.S. Treasury Financial Agent at 1-800-829-1040 no later than 14 business days prior to the payment (settlement) date. I also authorize the financial

institutions involved in the processing of the electronic payments of taxes to receive confidential information necessary to answer inquiries and

resolve issues related to the payments.

c. If you are unable to make electronic payments through a debit instrument (debit payments) by entering into a direct debit installment agreement

(DDIA) in Sections 8a. and b. above, please check the box below:

I am unable to make debit payments.

Note: Not checking this box indicates that you are able but choosing not to make debit payments. See Instructions for line 8c. for details.

If you want to make your payments by payroll deduction, check this box and attach a completed Form 2159, Payroll Deduction Agreement 9.

Part 2 - COLLECTION INFORMATION STATEMENT Complete Sections A through G below to provide financial information

A. ACCOUNTS / LINES OF CREDIT

PERSONAL BANK ACCOUNTS Include checking, online, mobile (e.g., PayPal), savings accounts, money market accounts. (Use additional sheets if

necessary.)

Name and Address of Institution

Account Number

Type of

Account

Current

Balance/Value

Check if

Business Account

Page 2

Catalog Number 71232U www.irs.gov

Form

433-H (Rev. 4-2020)

Part 2 - COLLECTION INFORMATION STATEMENT (Continued)

B. REAL ESTATE Include home, vacation property, timeshares, vacant land and other real estate. (Use additional sheets if necessary.)

Description/Location/County Monthly Payment(s) Financing Current Value Balance Owed Equity

Primary Residence Other

Year Purchased Purchase Price

Year Refinanced Refinance Amount

Primary Residence Other

Year Purchased Purchase Price

Year Refinanced Refinance Amount

Primary Residence Other

Year Purchased Purchase Price

Year Refinanced Refinance Amount

Primary Residence Other

Year Purchased Purchase Price

Year Refinanced Refinance Amount

C. OTHER ASSETS Include cars, boats, recreational vehicles, whole life policies, etc. Include make, model and year of vehicles and

name of Life Insurance company in Description. (Use additional sheets if necessary.)

Description Monthly Payment Year Purchased Final Payment (mo/yr) Current Value Balance Owed Equity

D. CREDIT CARDS (Visa, MasterCard, American Express, Department Stores, etc.)

Type Credit Limit Balance Owed Minimum Monthly Payment

INVESTMENTS Include Certificates of Deposit, Trusts, Individual Retirement Accounts (IRAs), Keogh Plans, Simplified Employee Pensions, 401(k)

Plans, Profit Sharing Plans, Mutual Funds, Stocks, Bonds, Commodities (Silver, Gold, etc.), and other investments. If applicable, include business

accounts. (Use additional sheets if necessary.)

Name and Address of Institution

Account Number

Type of

Account

Current

Balance/Value

Check if

Business Account

VIRTUAL CURRENCY (CRYPTOCURRENCY) List all virtual currency you own or in which you have a financial interest (e.g., Bitcoin, Ethereum,

Litecoin, Ripple, etc.). (Use additional sheets if necessary.)

Type of Virtual Currency

Name of Virtual Currency Wallet,

Exchange or Digital Currency

Exchange (DCE)

Email Address Used to Set-up

With the Virtual Currency

Exchange or DCE

Location(s) of Virtual Currency

(Mobile Wallet, Online, and/or

External Hardware storage)

Virtual Currency

Amount and Value in

US dollars as of today

(e.g., 10 Bitcoins

$64,600 USD)

Page 3

Catalog Number 71232U www.irs.gov

Form

433-H (Rev. 4-2020)

G. MONTHLY NECESSARY LIVING EXPENSES List monthly amounts. (For expenses paid other than monthly, see instructions.)

1. Food / Personal Care See instructions. National Standards for food,

clothing and other items apply nationwide. For expenses claimed in box

1, you should provide the IRS allowable standards

(found by accessing

IRS.gov and entering "Collection Financial Standards" in the search box) or your

actual expenses. If you claim a higher amount for a specific expense,

you must be able to verify that amount.

Actual Monthly

Expenses

IRS Allowed

Food

Housekeeping Supplies

Clothing and Clothing Services

Personal Care Products & Services

Miscellaneous

Total

2. Transportation

Actual Monthly

Expenses

IRS Allowed

Gas / Insurance / Licenses /

Parking / Maintenance etc.

Public Transportation

Total

3. Housing & Utilities

Actual Monthly

Expenses

IRS Allowed

Rent

Electric, Oil/Gas, Water/Trash

Telephone/Cell/Cable/Internet

Real Estate Taxes and Insurance

(if not included in B above)

Maintenance and Repairs

Total

Actual Monthly

Expenses

IRS Allowed

Health Insurance

Out of Pocket Health Care Expenses

Total

5. Other

Actual Monthly

Expenses

IRS Allowed

Child / Dependent Care

Estimated Tax Payments

Term Life Insurance

Retirement (Employer Required)

Retirement (Voluntary)

Union Dues

Delinquent State & Local Taxes

(minimum payment)

Student Loans (minimum payment)

Court Ordered Child Support

Court Ordered Alimony

Other Court Ordered Payments

Other (specify)

Total

4. Medical See instructions. National Standards for out of pocket health

case expenses. For expenses claimed in box 4, you should provide the

IRS allowable standards (found by accessing IRS.gov and entering

"Collection Financial Standards" in the search box)

or your actual expenses. If

you claim a higher amount for a specific expense, you must be able to

verify that amount.

Under penalty of perjury, I declare to the best of my knowledge and belief this request for installment agreement, statement of assets, liabilities and

income, and all other information is true, correct and complete. Further, I authorize the IRS to contact third parties and to disclose my tax information to

third parties in order to process this request and administer the agreement over its duration. I also agree to the terms of this agreement, as provided in

the instructions, if it is approved by the Internal Revenue Service.

Your Signature Spouse’s Signature Date

Part 2 - COLLECTION INFORMATION STATEMENT (Continued)

Notes

E. EMPLOYMENT INFORMATION If you have more than one employer, include the information on another sheet of paper. (If attaching

a copy of current pay stub, you do not need to complete the lines regarding gross pay and taxes.)

Your current employer (name and address)

How often are you paid (Check one)

Weekly Biweekly Semi-monthly Monthly

Gross per pay period

Taxes per pay period (Fed)

(State) (Local)

How long at current employer

Spouse’s current employer (name and address)

How often are you paid (Check one)

Weekly Biweekly Semi-monthly Monthly

Gross per pay period

Taxes per pay period (Fed)

(State) (Local)

How long at current employer

F. NON-WAGE HOUSEHOLD INCOME List monthly amounts.

Net Rental Income

Unemployment Income

Pension Income

Alimony Income

Child Support Income

Net Self Employment Income

Interest/Dividends Income

Social Security Income

Other

Page 4

Catalog Number 71232U www.irs.gov

Form

433-H (Rev. 4-2020)

Instructions for Form 433-H, Installment Agreement Request

and Collection Information Statement

What is the purpose of Form 433-H?

Form 433-H, Installment Agreement Request and

Collection Information Statement, is used by wage earners

to provide current financial information and request an

installment agreement, allowing the Service to determine

how best to satisfy outstanding tax liabilities.

However, before requesting an installment agreement,

you should consider other payment options, which

may be less costly, such as getting a bank loan or

using available credit on a credit card.

You must file all required returns that have not been filed.

Your request for an installment agreement will be denied if

all required tax returns have not been filed.

Use Form 433-H if you earn wages and are requesting an

installment agreement and either:

• You cannot pay your outstanding liability within 72

months, or

• Your outstanding liability exceeds $50,000.

Do not use Form 433-H if:

• Your outstanding liability is $50,000 or less and you

can pay within 72 months. Instead, use Form 9465,

Installment Agreement Request. See the tip below.

• You are self-employed. Instead, use Form 433-D,

Installment Agreement.

• You operate a business. Instead, use Form 433-D,

Installment Agreement.

TIP

If you can pay your outstanding liability within 120

days, there is no user fee for this type of

agreement, and you may be able to establish an

Online Payment Agreement (OPA). To apply online,

go to http://www irs.gov, and enter “Online Payment

Agreement" in the "Search" box.

TIP

If you owe $50,000 or less in combined tax,

penalties and interest and filed all required returns,

you may be able to establish an installment

agreement online. Go to IRS.gov to pay online. You

may owe a lower user fee if you establish your

agreement through the OPA application.

A large down payment to reduce your liability to $50,000

or less may streamline the installment agreement process,

pay your balance faster and reduce the amount of

penalties and interest charged.

Bankruptcy or offer-in-compromise. If you are in

bankruptcy or we have accepted your offer-in-

compromise, do not file this form. Instead, call

1-800-829-1040 to get the number of your local IRS

Insolvency function for bankruptcy or Technical Support

function for offer-incompromise.

Please retain a copy of your completed form and

supporting documentation. After we review your

completed form, we may contact you for additional

information. For example, we may ask you to send

supporting documentation of your current income or

substantiation of your stated expenditures.

Instructions

Part 1 – Installment Agreement Request

We will usually let you know within 30 days after we

receive your request whether it is approved or denied.

However, if this request is for tax due on a return you filed

after March 31, it may take us longer than 30 days to

reply.

We will review the financial information provided in

Sections A through G, determine your ability to pay and

compare it with the monthly payment amount you

proposed in Part 1, Line 6. We will contact you if we have

questions or believe you can pay your liability more

quickly.

If your request is approved, we will send you a notice

detailing the terms of your agreement and requesting a

fee of $225 ($107 if you make your payments by direct

debit).

Low income taxpayer. You are a low-income taxpayer if

your adjusted gross income meets the low-income

threshold (at or below 250% of the federal poverty

guidelines, as determined for the most recent year for

which information is available). You may qualify to pay a

reduced fee of $43 if your income is below a certain level.

The IRS will let you know whether you have low income

taxpayer status. If you agree to establish a direct debit

installment agreement (DDIA), you will not be charged a

user fee.

If the IRS does not say you qualify for low-income

taxpayer status, you can request reconsideration by using

Form 13844, Application For Reduced User Fee For

Installment Agreements. The user fee for low income

taxpayers is $43, which may be waived or reimbursed if

certain conditions are met. See the instructions for line 8c.

for details.

You will also be charged interest and may be charged a

late payment penalty on any tax not paid by its due date,

even if your request to pay in installments is granted.

Interest and any applicable penalties will be charged until

the balance is paid in full. To limit interest and penalty

charges, file your return on time and pay as much of the

tax as possible with your return (or notice).

By approving your request, we agree to let you pay the tax

you owe in monthly installments instead of immediately

paying the amount in full. In return, you agree to make

your monthly payments on time. You agree to provide

updated financial information when requested.

You also agree to meet all your future tax obligations. This

means that you must have enough withholding or

estimated tax payments so that your tax obligation for

future years is paid in full when payment is due. And you

agree to timely file your return.

Page 5

Catalog Number 71232U www.irs.gov

Form

433-H (Rev. 4-2020)

Part 1 – Installment Agreement Request

(Continued)

Any refund you are due in a future year will be applied

against the amount you owe. If your refund is applied to

your balance, you are still required to make your regular

monthly installment payment.

Payment methods. You can make your payments by

check, money order, credit card, or one of the other

payment methods shown next. The fee for setting up an

installment agreement for each payment method is also

shown.

Payment Method Applicable User Fee

Check, money order, credit card

or payroll deduction installment

agreement

$225

Direct debit installment

agreement

$107

Your specific tax situation will determine which payment

options are available to you. You may owe a lower user

fee if you establish your agreement through the OPA

application on the IRS web site; however, not all taxpayers

qualify to apply for an installment agreement online to pay

off their balance over time. Go to IRS.gov, and enter

“Online Payment Agreement” in the “Search” box for more

information.

After we receive each payment, we will send you a notice

showing the remaining amount you owe, and the due date

and amount of your next payment. But if you choose to

have your payments automatically withdrawn from your

checking account, you will not receive a notice. Your bank

statement is your record of payment.

We will also send you an annual statement showing the

amount you owed at the beginning of the year, all

payments made during the year, and the amount you owe

at the end of the year.

What happens if the taxpayer doesn’t comply with the

terms of the installment agreement? If you do not make

your payments on time or do not pay any balance due on

a return you file later, you will be in default on your

agreement and we may terminate the agreement and take

enforcement actions, such as the filing of a Notice of

Federal Tax Lien or initiating an IRS levy action, to collect

the entire amount you owe.

For additional information on the IRS collection process,

see Pub. 594, The IRS Collection Process, or Pub. 1,

Know Your Rights as a Taxpayer. You may also visit

IRS.gov

and put “collection process” into the "Search"

box. To ensure that your payments are made timely, you

should consider making them by direct debit. See the

instructions for lines 8a and 8b on page 5.

▲

CAUTION

An installment agreement may be terminated if

you provide materially incomplete or inaccurate

information in response to an IRS request for a

financial update.

Notice of Federal Tax Lien. A Notice of Federal Tax Lien

(NFTL) may be filed to protect the government’s interests

until you pay in full. If you meet certain criteria, you may

be able to get the NFTL withdrawn. To learn more about

NFTL withdrawals and to see if you qualify, visit www.irs.

gov and enter "lien" in the “Search” box.

Where To File

Send Form 433-H, Installment Agreement Request and

Collection Information Statement, with any attachments,

to the Internal Revenue Service Center at the address in

the table below that applies to you.

IF you live in . . .

THEN use this

address . . .

Alaska, Arizona, Colorado,

Connecticut, Delaware, District

of Columbia, Hawaii, Idaho,

llinois, Maine, Maryland,

Massachusetts, Montana, New

Hampshire, New Jersey, New

Mexico, Nevada,

North Dakota, Oregon, Rhode

Island, South Dakota,

Tennessee, Utah, Vermont,

Washington,

Wisconsin, Wyoming

Internal Revenue Service

PO Box 9041

CSCO Bal Due

Andover, MA

01810-9041

Alabama, Florida, Georgia,

Kentucky, Louisiana,

Mississippi, North Carolina,

South Carolina, Texas, Virginia

Internal Revenue Service

PO Box 47421, Stop 74

Doraville, GA 30362

Arkansas, California, Iowa,

Indiana, Kansas, Michigan,

Minnesota, Missouri,

Nebraska, New York, Ohio,

Oklahoma, Pennsylvania,

West Virginia

Internal Revenue Service

Stop P-4 5000

PO Box 219236

Kansas City, MO

64121-9236

A foreign country, American

Samoa, or Puerto Rico (or are

excluding income under

Internal

Revenue Code section 933),

Guam, the U.S. Virgin Islands,

or use an APO or FPO

address, or

file Form 2555, 2555-EZ, or

4563, or are a dual-status alien

Internal Revenue Service

CSCO Stop 4-N31.142

2970 Market St.

Philadelphia, PA 19104

For all taxpayers who are bona fide residents of Guam,

the U.S. Virgin Islands, or the Commonwealth of the

Northern Mariana Islands, See Pub. 570, Tax Guide for

Income From U.S. Possessions.

Page 6

Catalog Number 71232U www.irs.gov

Form

433-H (Rev. 4-2020)

Part 1 – Installment Agreement Request

(Continued)

Line 1

Enter the tax form, tax period, and the total amount you

owe as shown on your tax return(s) (or notice(s)).

Line 2

List additional tax forms, tax periods, and balances due

that are not reflected on Line 1 (even if they are included

in an existing installment agreement).

Line 3

Add lines 1 & 2 and enter the result.

Line 4

Enter the amount of the payment you are making with this

request.

Even if you cannot pay the full amount you owe now, you

should pay as much as possible to limit penalty and

interest charges. If you are filing this form with your tax

return, make the payment with your return. For details on

how to pay, see your tax return instructions.

Attach a check or money order payable to “United States

Treasury.” Do not send cash. Be sure to include:

• Your name, address, SSN/ITN, and daytime phone

number.

• The tax year and tax return (for example, “2012

Form 1040”) for which you are making this request.

Line 5

Subtract line 4 from line 3 and enter the result.

Line 6

Enter the amount you can pay each month. Make your

payments as large as possible to limit interest and penalty

charges. The charges will continue until you pay in full. (If

you have an existing installment agreement, this amount

should represent your total proposed monthly payment

amount for all your liabilities.)

If no payment amount is listed on line 6, a payment will be

determined for you by analyzing the information provided

on your financial statement.

Line 7

You can choose the day of each month your payment is

due. This can be on or after the 1st oft he month, but no

later than the 28th of the month. For example, if your rent

or mortgage payment is due on the 1st of the month, you

may want to make your installment payments on the 15th.

If we approve your request, we will tell you the month and

day that your first payment is due.

If we have not replied by the date you chose for your first

payment, you can send the first payment to the Internal

Revenue Service Center at the address shown earlier that

applies to you. See the instructions for line 4 for details on

what to write on your payment.

Line 8a, 8b, and 8c

TIP

Making your payments by direct debit will help

ensure that your payments are made timely and

that you are not in default of this agreement.

To pay by direct debit from your checking account at a

bank or other financial institution (such as a mutual fund,

brokerage firm, or credit union), fill in lines 8a and 8b.

Check with your financial institution to make sure that a

direct debit is allowed and to get the correct routing and

account numbers.

Line 8a. The routing number must be nine digits. The

first two digits of the routing number must be 01 through

12 or 21 through 32. Use a check to verify the routing

number. On the following sample check, the routing

number is 250250025. But if your check is payable

through a financial institution different from the one at

which you have your checking account, do not use the

routing number on that check. Instead, contact your

financial institution for the correct routing number.

Line 8b. The account number can be up to 17

characters (both numbers and letters). Include hyphens

but omit spaces and special symbols. Enter the number

from left to right and leave any unused boxes blank. On

the following sample check, the account number is

20202086. Do not include the check number.

▲

CAUTION

We may file a Notice of Federal Tax Lien (NFTL)

against you, or may have previously filed one. If

you meet certain criteria, you may be able to get

the NFTL withdrawn. To learn more about NFTL

withdrawals and to see if you qualify, visit IRS gov

and enter "lien" in the “Search” box.

If you qualify as a low income taxpayer, you will receive a

waiver of the installment agreement user fees if you agree

to make electronic payments through a debit instrument

(debit payments) by following the direct debit instructions

in lines 8 a. and b.

Line 8c. If you are a low income taxpayer that is unable to

make debit payments, please indicate by checking the box

in line 8c. to receive a reimbursement of the reduced user

fees upon completion of your agreement.

If you do not check the box in line 8c. and you do not

provide your checking account information in lines 8a. and

b., then you will be treated as being able to but choosing

not to make debit payments and your user fees will not be

reimbursed upon completion of your installment

agreement.

Page 7

Catalog Number 71232U www.irs.gov

Form

433-H (Rev. 4-2020)

Part 1 – Installment Agreement Request

(Continued)

Sample Check - Lines 8a and 8b

Paul Maple

Roberta Maple

123 Pear Lane

Anyplace, VA 20000

PAY TO THE

ORDER OF

DOLLARS

1234

15-000000000

ANYPLACE BANK

Anyplace, VA 20000

For

SAMPLE

|:250250025| :202020"'86". 1234

Routing

Number

Line 8a

Account

Number

Line 8b

Do not inlude

the check number.

◀

▲

The routing and account numbers may be in different places on your

check.

Line 9

If you want to make your payments by payroll deduction,

check the box on line 9 and attach a completed and

signed Form 2159, Payroll Deduction Agreement, with

your request. Ask your employer to complete and sign

their portion of Form 2159, Payroll Deduction Agreement.

Part 2 – Collection Information Statement

Section A – Accounts/Lines of Credit

List all accounts, even if they currently have no balance.

However, do not enter bank loans in this section. Include

business accounts, if applicable. If you are entering

information for a stock or bond, etc. and a column box

does not apply, enter N/A.

Section B – Real Estate

List all real estate you own or are purchasing including

your home. Include insurance, taxes and homeowner's

association dues if they are included in your monthly

payment. The county/description is needed if different

than the address and county you listed above. To

determine equity, subtract the amount owed for each

piece of real estate from its current market value.

Section C – Other Assets

List all cars, boats and recreational vehicles with their

make, model and year. If a vehicle is leased, write “lease”

in the “year purchased” column. List whole life insurance

policies with the name of the insurance company. List

other assets with a description such as “paintings”, “coin

collection”, or “antiques”. If applicable, include business

assets, such as tools, equipment, inventory, and intangible

assets such as domain names, patents, copyrights, etc.

To determine equity, subtract the amount owed from its

current market value. If you are entering information for an

asset and a column box does not apply, enter N/A.

Section D – Credit Cards

List all credit cards and lines of credit, even if there is no

balance owed.

Section E – Employment Information

Enter wage information for you or your spouse as

applicable. If attaching a copy of current pay stub(s), you

do not need to complete this section.

Section F – Non-Wage Household Income

List all non-wage income received monthly.

Other Income includes 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. It also includes agricultural subsidies,

gambling income, and oil credits. Enter total distributions

from RAs if not included under Pension Income.

Section G – Monthly Necessary Living Expenses

Enter monthly amounts for expenses. For any expenses

not paid monthly, convert as follows:

If a bill is paid

Calculate the

monthly amount by

Quarterly Dividing by 3

Weekly Multiplying by 4 3

Biweekly (every two weeks) Multiplying by 2.17

Semimonthly (twice each month) Multiplying by 2

National Standards for food, clothing and other items

apply nationwide. For expenses claimed in boxes 1 and 4

you should provide the IRS allowable standards that can

be found by accessing IRS.gov and entering “Collection

Financial Standards” in the search box.

If you claim a higher amount for a specific expense, you

must verify and substantiate that amount.

The amount claimed for Miscellaneous cannot exceed the

standard amount for the number of people in your family.

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.

If you do not have access to the IRS web site, itemize

your actual expenses and we will ask you for additional

proof, if required. Documentation may include pay

statements, bank and investment statements, loan

statements and bills for recurring expenses, etc.

Housing and Utilities – Includes expenses for your

primary residence. You should only list amounts for

utilities, taxes, insurance and homeowner's association

dues that are not included in your mortgage or rent

payments.

Rent – Do not enter mortgage payment here. Mortgage

payment is listed in Section B.

Transportation – Include the total of maintenance,

repairs, insurance, fuel, registrations, licenses,

inspections, parking, and tolls for one month.

Page 8

Catalog Number 71232U www.irs.gov

Form

433-H (Rev. 4-2020)

Public Transportation – Include the total you spend for

public transportation if you do not own a vehicle or if you

have public transportation costs in addition to vehicle

expenses.

Medical – You are allowed expenses for health insurance

and out-of-pocket health care costs.

Health insurance – Enter the monthly amount you pay for

yourself or your family.

Out-of-Pocket health care expenses – Are costs not

covered by health insurance, and include:

• Medical services

• Prescription drugs

• Dental expenses

• Medical supplies, including eyeglasses and contact

lenses. Medical procedures of a purely cosmetic

nature, such as plastic surgery or elective dental

work are generally not allowed.

Child / Dependent Care – Enter the monthly amount

you pay for the care of dependents that can be claimed

on your Form 1040.

Estimated Tax Payments – Calculate the monthly

amount you pay for estimated taxes by dividing the

quarterly amount due on your Form 1040ES by 3.

Life Insurance – Enter the amount you pay for term life

insurance only. Whole life insurance has cash value and

should be listed in Section C.

Delinquent State & Local Taxes – Enter the minimum

amount you are required to pay monthly. Be prepared to

provide a copy of the statement showing the amount you

owe and if applicable, any agreement you have for

monthly payments.

Student Loans – Minimum payments on student loans

for the taxpayer’s post-secondary education may be

allowed if they are guaranteed by the federal

government. Be prepared to provide proof of loan

balance and payments.

Court Ordered Payments – For any court ordered

payments, be prepared to submit a copy of the court

order portion showing the amount you are ordered to

pay, the signatures, and proof you are making the

payments. Acceptable forms of proof are copies of

cancelled checks or copies of bank or pay statements.

Other Expenses (not listed above) – We may allow

other expenses in certain circumstances. For example, if

the expenses are necessary for the health and welfare of

the taxpayer or family, or for the production of income.

Specify the expense and list the minimum monthly

payment you are billed.

Signature(s) & Date - Review the terms of this

agreement and financial information entered. Please

sign and date this completed agreement form. Then,

return it to IRS at the address

shown on page 5.

Privacy Act and Paperwork Reduction Act Notice.

Our legal right to ask for the information on this form is

sections 6001, 6011, 6012(a), 6109, and 6159 and their

regulations. We will use the information to process your

request for an installment agreement. The reason we

need your name and social security number is to secure

proper identification. We require this information to gain

access to the tax information in our files and properly

respond to your request. You are not required to request

an installment agreement. If you do request an installment

agreement, you are required to provide the information

requested on this form. Failure to provide this information

may prevent processing your request; providing false

information may subject you to fines or penalties.

You are not required to provide the information requested

on a form that is subject to the Paperwork Reduction Act

unless the form displays a valid OMB control number.

Books or records relating to a form or its instructions must

be retained as long as their contents may become

material in the administration of any Internal Revenue law.

Generally, tax returns and return information are

confidential, as required by section 6103. However, we

may give this information to the Department of Justice for

civil and criminal litigation, and to cities, states, the District

of Columbia, and U.S. commonwealths and possessions

to carry out their tax laws. We may also disclose this

information to other countries under a tax treaty, to federal

and state agencies to enforce federal nontax criminal

laws, or to federal law enforcement and intelligence

agencies to combat terrorism.

The average time and expenses required to complete and

file this form will vary depending on individual

circumstances. For the estimated averages, see the

instructions for your income tax return.

If you have suggestions for making this form simpler, we

would be happy to hear from you. See the instructions for

your income tax return.