Form RI433 A "Collection Information Statement for Wage Earners and Self-employed Individuals" - Rhode Island

What Is Form RI433 A?

This is a legal form that was released by the Rhode Island Department of Revenue - Division of Taxation - a government authority operating within Rhode Island. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2002;
  • The latest edition provided by the Rhode Island Department of Revenue - Division of Taxation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form RI433 A by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Revenue - Division of Taxation.

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Download Form RI433 A "Collection Information Statement for Wage Earners and Self-employed Individuals" - Rhode Island

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RI 433 A
COLLECTION INFORMATION STATEMENT FOR WAGE EARNERS
AND SELF-EMPLOYED INDIVIDUALS
Rhode Island Division
of Taxation
Complete all entry spaces with the most current data available
(Revised 11/02)
Write "N/A" (not applicable) in spaces that do not apply.
Section 1
Full Name(s)
Home Telephone (
)
Best Time To Call:
Personal
Street Address
Info
Marital Status:
City________________________________ State_________Zip____________
( ) Married ( ) Separated
( ) Single
Your Social Security Number
____/___/_____
Date of Birth
___/___/_____
Spouse's Social Security Number
____/___/_____
Spouse's DOB
___/___/_____
( ) Own Home ( ) Rent ( ) Other (specify, i.e. share rent, live with relative)
List the dependents you can claim on your tax return: (Attach sheet if more space is needed)
First Name Relationship Age
Does This Person
First Name Relationship Age
Does This Person
Live With You
Live With You
( ) No ( ) Yes
( ) No ( ) Yes
( ) No ( ) Yes
( ) No ( ) Yes
( ) No ( ) Yes
( ) No ( ) Yes
Adjusted Gross Income from Current Year Filing of Federal Personal Income Tax Return:
$
Are you or your spouse self-employed or a partner operating a business?
Section 2
Sole Proprietor ( )
Partnership ( )
Name of Business
Employer I.D. No.
Your
Business
Street Address
Business Telephone
(
) ______________
Info
City __________________________State _____ Zip ___________
Do you have employees? ( ) No ( ) Yes
Do you have accounts receivable?
( ) No ( ) Yes
Employer
Spouse's Employer
Section 3
Street Address
Street Address
City ___________________State _____ Zip _________
City ___________________State _____ Zip _________
Employ-
ment Info
Work Telephone No.
(
)______(
)______________
Work Telephone No. (
)______________
May we contact you at work? ( ) No ( ) Yes
May we contact you at work? ( ) No ( ) Yes
Occupation __________________________________
Occupation____________________________________
Do you receive income from sources other than your own business or employer? (Check all that apply)
Section 4
( ) Pension
( ) Social Security
( ) Other (specify, i.e. child support, alimony, rental)_________________
Other
Income
Info
RI 433 A
COLLECTION INFORMATION STATEMENT FOR WAGE EARNERS
AND SELF-EMPLOYED INDIVIDUALS
Rhode Island Division
of Taxation
Complete all entry spaces with the most current data available
(Revised 11/02)
Write "N/A" (not applicable) in spaces that do not apply.
Section 1
Full Name(s)
Home Telephone (
)
Best Time To Call:
Personal
Street Address
Info
Marital Status:
City________________________________ State_________Zip____________
( ) Married ( ) Separated
( ) Single
Your Social Security Number
____/___/_____
Date of Birth
___/___/_____
Spouse's Social Security Number
____/___/_____
Spouse's DOB
___/___/_____
( ) Own Home ( ) Rent ( ) Other (specify, i.e. share rent, live with relative)
List the dependents you can claim on your tax return: (Attach sheet if more space is needed)
First Name Relationship Age
Does This Person
First Name Relationship Age
Does This Person
Live With You
Live With You
( ) No ( ) Yes
( ) No ( ) Yes
( ) No ( ) Yes
( ) No ( ) Yes
( ) No ( ) Yes
( ) No ( ) Yes
Adjusted Gross Income from Current Year Filing of Federal Personal Income Tax Return:
$
Are you or your spouse self-employed or a partner operating a business?
Section 2
Sole Proprietor ( )
Partnership ( )
Name of Business
Employer I.D. No.
Your
Business
Street Address
Business Telephone
(
) ______________
Info
City __________________________State _____ Zip ___________
Do you have employees? ( ) No ( ) Yes
Do you have accounts receivable?
( ) No ( ) Yes
Employer
Spouse's Employer
Section 3
Street Address
Street Address
City ___________________State _____ Zip _________
City ___________________State _____ Zip _________
Employ-
ment Info
Work Telephone No.
(
)______(
)______________
Work Telephone No. (
)______________
May we contact you at work? ( ) No ( ) Yes
May we contact you at work? ( ) No ( ) Yes
Occupation __________________________________
Occupation____________________________________
Do you receive income from sources other than your own business or employer? (Check all that apply)
Section 4
( ) Pension
( ) Social Security
( ) Other (specify, i.e. child support, alimony, rental)_________________
Other
Income
Info
Page 2
CHECKING ACCOUNTS.
List all checking accounts. ( If additional space is needed, attach a separate sheet.)
Section 5
Type of
Full Name of Bank, Savings & Loan,
Bank Account No.
Current Balance
Banking
Account
Credit Union or Financial Institution
Investment
Cash
Checking
Name_______________________________________
_________________ $ _______________
Credit
Street Address _______________________________
Life Ins-
City/State/Zip _______________________________
urance
Checking
Name_______________________________________
_________________ $ _______________
Street Address _______________________________
City/State/Zip _______________________________
Total Checking Account Balances
$ _______________
OTHER ACCOUNTS.
List all accounts,including brokerage, savings, and money market, not listed previously.
Type of
Full Name of Bank, Savings & Loan,
Bank Account No.
Current Balance
Account
Credit Union or Financial Institution
Name_______________________________________
_________________ $ _______________
Street Address _______________________________
City/State/Zip _______________________________
Name_______________________________________
_________________ $ _______________
Street Address _______________________________
City/State/Zip _______________________________
Total Other Account Balances
$ _______________
INVESTMENTS.
Name of Company
Number of
Current
Loan
Used as collateral
Shares/Units
Value
Amount
on loan
Current
____________
$
$
( ) No
( ) Yes
Value:
Indicate
____________
$
$
( ) No
( ) Yes
the amount
you could
____________
$
$
( ) No
( ) Yes
sell the
asset for
today.
Total Investments
$ _______________
CASH ON HAND.
Include any money that you have that is not in the bank.
Total Cash on Hand
$ _______________
AVAILABLE CREDIT.
List all lines of credit, including credit cards.
Full Name of
Credit Institution
Credit Limit
Amount Owed
Available Credit
Name_______________________________________
$ _______________ $ _______________ $ _______________
Street Address _______________________________
City/State/Zip _______________________________
Name_______________________________________
$ _______________ $ _______________ $ _______________
Street Address _______________________________
City/State/Zip _______________________________
Total Credit Available
$ _______________
Page 3
LIFE INSURANCE.
Do you have life insurance with a cash value?
( ) No
( ) Yes
Section 5
(Term Life Insurance does not have a cash value.)
Continued
If yes:
Name of Insurance Company
Policy Number(s)
Owner of Policy
Current Cash Value
Outstanding Loan Balance
$
$
Net Difference of Current Cash Value and Outstanding Loan Balance
$
OTHER INFORMATION.
Section 6
Are there any garnishments against your wages?
( ) No ( ) Yes
Other
If yes, who is the creditor?"
Date of Judgement
Amt Owed $
Information
Are there any other judgements against you?
( ) No ( ) Yes
If yes, who is the creditor?"
Date of Judgement
Amt Owed $
Are you a party in a lawsuit?
( ) No ( ) Yes
If yes, amount of suit $_______________ Possible completion date________ Subject matter of suit________________
Did you ever file bankruptcy?
( ) No ( ) Yes
If yes, date filed_____________________ Date discharged_______________________
Are you a beneficiary of a trust or an estate?
( ) No ( ) Yes
If yes, name of trust or estate____________________________
Anticipated amount to be received $_______________
Are you a participant in a profit sharing plan?
( ) No ( ) Yes
If yes, name of plan____________________________________ Value in plan $________________________
PURCHASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS:
Include boats, RV's motorcycles,
Section 7
(If you need additional space, attach a separate sheet.)
trailers, etc.
Assets and
Description
Current
Current
Name of
Purchase Amount of
Liabilities
Value
Loan
Lender
Date
Monthly
Balance
Payment
Year
__________________
Make/Model_________________
Mileage_____________________ $________________
_______ $ _______
Description
Current
Current
Name of
Purchase Amount of
Value
Loan
Lender
Date
Monthly
Balance
Payment
Year
__________________
Make/Model_________________
Mileage_____________________ $
$
_______ $ _______
Description
Current
Current
Name of
Purchase Amount of
Value
Loan
Lender
Date
Monthly
Balance
Payment
Year
__________________
Make/Model_________________
Mileage_____________________ $
$
_______ $ _______
Page 4
LEASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS.
Include boats, RV's motorcycles,
Section 7
(If you need additional space, attach a separate sheet.)
trailers, etc.
Continued
Description
Current
Current
Name of
Purchase Amount of
Value
Loan
Lender
Date
Monthly
Balance
Payment
Year
__________________
Make/Model_________________
Mileage_____________________ $
$
_______ $
Description
Current
Current
Name of
Purchase Amount of
Value
Loan
Lender
Date
Monthly
Balance
Payment
Year
__________________
Make/Model_________________
Mileage_____________________ $
$
_______ $
REAL ESTATE.
List all real estate you own. (If you need additional space, attach a separate sheeet.)
Street Address, City,
Date
Purchase Current
Loan
Name of Lender
Amount of Date of
State, Zip and County Purchased Price
Value
Balance
or Lien Holder
Monthly
Final
Payment
Payment
_______ $_______ $_______ $_______
$_______
_______ $_______ $_______ $_______
$_______
PERSONAL ASSETS. List all personal assets below. (If you need additional space, attach a separate sheet.)
Furniture/Personal Effects includes the total current market value of your household such as furniture and
appliances. Other personal assets includes all artwork, jewelry, collections (coin, gun, etc.), antiques or
other assets.
Description
Current
Loan
Name of Lender
Amount
Date of
Value
Balance
of Monthly Final
Payment
Payment
Furniture/Personal Effects
Other:
Artwork
$_______ $_______ ___________________________ $_______ ________
Jewelry
$_______ $_______ ___________________________ $_______ ________
$_______ $_______ ___________________________ $_______ ________
$_______ $_______ ___________________________ $_______ ________
BUSINESS ASSETS. List all business assets and encumbrances below.
Description
Current
Loan
Name of Lender
Amount
Date of
Value
Balance
of Monthly Final
Tools used in Trade/Business
$_______ $_______ ___________________________ $_______ ________
Other:
Machinery
$_______ $_______ ___________________________ $_______ ________
Equipment
$_______ $_______ ___________________________ $_______ ________
$_______ $_______ ___________________________ $_______ ________
$_______ $_______ ___________________________ $_______ ________
Page 5
Other Liabilities (including judgements, notes, other charge accounts, Federal taxes)
Section 7
Continued
Balance
Name of Lender
Monthly
Date of
Description
Owed
Payment
Final Pmt
Federal Tax Liability
$_______ ___________________________ $_______ ________
___________________________ $_______ ___________________________ $_______ ________
___________________________ $_______ ___________________________ $_______ ________
___________________________ $_______ ___________________________ $_______ ________
___________________________ $_______ ___________________________ $_______ ________
___________________________ $_______ ___________________________ $_______ ________
Total Other Liabilities
$
REFERENCES:
Name, address and telephone number of next of kin or other reference.
Section 8
Prior
Name
Telephone Number (
)_____________
History
Street Address
City, State, Zip
Prior names or aliases used by you.
Prior address, if present address is less than two years old.
Total Income
Total Living Expenses
Section 9
Source
Gross Monthly
Expense Items
Actual Monthly
Monthly
Wages(Yourself)
$ ______________
Food, Clothing, Misc.
$ ______________
Income and
Wages(Spouse)
______________
Housing and Utiliities
______________
Expense
Interest/Dividends
______________
Transportation
______________
Analysis
Net Income from Business
______________
Health Care
______________
Net Rental Income
______________
Taxes
______________
Pension/Soc Sec (Yourself)
______________
Court Ordered Payments
______________
Pension/Soc Sec (Spouse)
______________
Child/Dependent care
______________
Child Support
______________
Life Insurance
______________
Alimony
______________
Other Secured Debt
______________
Other
______________
Other Expenses
______________
Total Income
$ ______________
Total Living Expenses
$ ______________
Total Income less Total Living Expenses:
$________________
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.
_____________________________________
____________________________________ ________
Your Signature
Spouse's Signature
Date
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