Form MD433-A "Collection Information Statement for Individuals" - Maryland

What Is Form MD433-A?

This is a legal form that was released by the Comptroller of Maryland - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2000;
  • The latest edition provided by the Comptroller of Maryland;
  • 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 MD433-A by clicking the link below or browse more documents and templates provided by the Comptroller of Maryland.

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Download Form MD433-A "Collection Information Statement for Individuals" - Maryland

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MD 433-A
Form
(Rev. July 2000)
Collection Information Statement for Individuals
State of Maryland
(If you need additional space, please attach a separate sheet)
Comptroller of Maryland
Note: Complete all blocks, except shaded areas. Write “N/A” (not applicable) in those blocks that do not apply.
1 Taxpayer(s) name(s) and address
2 Home phone number
3 Marital status
(
)
4a Taxpayer’s Social Security number
4b Spouse’s Social Security number
County ______________________
Section I
Employment Information
5 Taxpayer’s employer or business
a How long employed
b Business phone number
c Occupation
(name and address)
e Pay period: ! Weekly
! Bi-weekly
d Number of exemptions
f (Check appropriate box)
! Monthly
! ________
! Wage earner
claimed on W-4
! Sole proprietor
! Partner
Payday: ___________ (Mon-Sun)
6 Spouse’s employer or business
a How long employed
b Business phone number
c Occupation
(name and address)
e Pay period: ! Weekly
! Bi-weekly
d Number of exemptions
f (Check appropriate box)
! Monthly
! ________
! Wage earner
claimed on W-4
! Sole proprietor
! Partner
Payday: ___________ (Mon-Sun)
Section II
Personal Information
7 Name, address and telephone number of
8 Other names or aliases
9 Previous address(es)
next of kin or other reference
10 Age and relationship of dependents living in your household (exclude yourself and spouse)
11 Date
a Taxpayer
b Spouse
12 Last filed income
a Number of exemptions
b Adjusted gross income
of birth
tax return (tax year)
claimed
Section III
General Financial Information
13 Bank accounts (include savings and loans, credit unions, IRA and retirement plans, certificates of deposit, etc.)
Name of Institution
Address
Type of Account
Account No.
Balance
Total (Enter in Item 21) ..................................................................................................................................................................................
MD 433-A
Form
(Rev. July 2000)
Collection Information Statement for Individuals
State of Maryland
(If you need additional space, please attach a separate sheet)
Comptroller of Maryland
Note: Complete all blocks, except shaded areas. Write “N/A” (not applicable) in those blocks that do not apply.
1 Taxpayer(s) name(s) and address
2 Home phone number
3 Marital status
(
)
4a Taxpayer’s Social Security number
4b Spouse’s Social Security number
County ______________________
Section I
Employment Information
5 Taxpayer’s employer or business
a How long employed
b Business phone number
c Occupation
(name and address)
e Pay period: ! Weekly
! Bi-weekly
d Number of exemptions
f (Check appropriate box)
! Monthly
! ________
! Wage earner
claimed on W-4
! Sole proprietor
! Partner
Payday: ___________ (Mon-Sun)
6 Spouse’s employer or business
a How long employed
b Business phone number
c Occupation
(name and address)
e Pay period: ! Weekly
! Bi-weekly
d Number of exemptions
f (Check appropriate box)
! Monthly
! ________
! Wage earner
claimed on W-4
! Sole proprietor
! Partner
Payday: ___________ (Mon-Sun)
Section II
Personal Information
7 Name, address and telephone number of
8 Other names or aliases
9 Previous address(es)
next of kin or other reference
10 Age and relationship of dependents living in your household (exclude yourself and spouse)
11 Date
a Taxpayer
b Spouse
12 Last filed income
a Number of exemptions
b Adjusted gross income
of birth
tax return (tax year)
claimed
Section III
General Financial Information
13 Bank accounts (include savings and loans, credit unions, IRA and retirement plans, certificates of deposit, etc.)
Name of Institution
Address
Type of Account
Account No.
Balance
Total (Enter in Item 21) ..................................................................................................................................................................................
Form MD 433-A
Page 2
(Rev. 7-2000)
Section III (continued) General Financial Information
14 Charge cards and lines of credit from banks, credit unions, and savings and loans.
Type of Account
Name and Address of
Monthly
Credit
Amount
Credit
or Card
Financial institution
Payment
Limit
Owed
Available
Total (Enter in Item 27) ..........................................................................................
15 Safe deposit boxes rented or accessed (List all locations, box numbers, and contents)
16 Real Property (Brief description and type of ownership)
Physical Address
a
County _________________________________
b
County _________________________________
c
County _________________________________
17 Life Insurance (Name and Company)
Policy Number
Type
Face Amount
Available Loan Value
! Whole
! Term
! Whole
! Term
! Whole
! Term
Total (Enter in Item 23)
18 Securities (stocks, bonds, mutual funds, money market funds, government securities, etc.):
Kind
Quantity or
Current
Where
Owner
Denomination
Value
Located
of Record
19 Other information relating to your financial condition. If you check the “Yes” box, please give dates and explain on page 4, Additional
Information or Comments:
! Yes
! No
! Yes
! No
a Court proceedings
b Bankruptcies
! Yes
! No
! Yes
! No
c Repossessions
d Recent sale or other transfer of
assets for less than full value
! Yes
! No
! Yes
! No
e Anticipated increase
f Participant or beneficiary
in income
to trust, estate, profit sharing, etc.
Form MD 433-A
Page 3
(Rev. 7-2000)
Section IV
Assets and Liabilities
Current
Current
Equity
Amount of
Name and Address of
Date
Date of
Description
Market
Amount
in
Monthly
Lien/Note Holder/Lender
Pledged
Final
Value
Owed
Asset
Payment
Payment
20 Cash
21 Bank accounts (from item 13)
22 Securities (from item 18)
23 Cash or loan value of insurance
24 Vehicles leased or owned
(model, year, license, tag #)
a
b
c
25 Real property
a
(from Section III,
item 16)
b
c
26 Other assets
a
b
c
d
e
27 Bank revolving credit (from item 14)
28 Other liabilities
a
(including bank
loans, judgements b
notes, and
charge accounts
c
not entered in
item 13)
d
e
f
g
29 Federal taxes owed (prior years)
29 Totals
$
$
Comptroller of Maryland Use Only Below This Line
Financial Verification/Analysis
Date Information or
Date Property
Estimated Forced
Item
Encumbrance Verified
Inspected
Sale Equity
Personal Residence
Other real property
Vehicles
Other personal property
State employment (husband and wife)
Income tax return
Wage statements (husband and wife)
Sources of income/credit (D&B report)
Expenses
Other assets/liabilities
Form MD 433-A
Page 4
(Rev. 7-2000)
Section V
Monthly Income and Expense Analysis
Total Income
Necessary Living Expenses
Comptroller’s use Only
Source
Gross
Claimed
Allowed
31 Wages/salaries (taxpayer)
$
42 National Standard Expenses (1)
$
$
32 Wages/salaries (spouse)
43 Housing and utilities (2)
33 Interest, dividends
44 Transportation (3)
34 Net business income
45 Health care
(from Form MD 433-B)
35 Rental income
46 Taxes (income and FICA)
36 Pension (taxpayer)
47 Court ordered payments
37 Pension (spouse)
48 Child/dependent care
38 Child support
49 Life insurance
39 Alimony
50 Secured or legally-perfected
debts (specify)
40 Other income
51 Other expenses (specify)
41 Total income
$
52 Total Expenses
$
$
53 (Comptroller’s use only) Net
$
difference (income less necessary
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.
54 Your signature
55 Spouse’s signature (if joint return filed)
56 Date
Notes
1 Clothing and clothing services, food, housekeeping supplies, personal care products and services, and miscellaneous.
2 Rent or mortgage payment for the taxpayer’s principal residence. Add the average monthly payment for the following expenses if they are not
included in the rent or mortgage payment: property taxes, homeowner’s or renter’s insurance, parking, necessary maintenance and repair,
homeowner dues, condominium fees and utilities. Utilities include gas, electricity, water, fuel oil, coal, bottled gas, trash and garbage collection,
wood and other fuels, septic cleaning, and telephone.
3 Lease or purchase payments, insurance, registration fees, normal maintenance, fuel, public transportation, parking, and tolls.
Additional information or comments:
Comptroller of Maryland Use Only Below This Line
Explain any difference between Item 53 and the installment payment amount:
Name of Originator
Date
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