Federal Collection Information Statement for Businesses

Collection Information Statement for Businesses
Form 433-B (Rev. 2-2019)
Form

433-B

Collection Information Statement for Businesses

(February 2019)
Department of the Treasury
Internal Revenue Service

Note: Complete all entry spaces with the current data available or "N/A" (not applicable). Failure to complete all entry spaces may result in rejection of
your request or significant delay in account resolution. Include attachments if additional space is needed to respond completely to any question.

Section 1: Business Information
1a Business Name

2a Employer Identification No. (EIN)
2b Type of entity (Check appropriate box below)
Partnership
Corporation
Other
Limited Liability Company (LLC) classified as a corporation
Other LLC - Include number of members
2c Date Incorporated/Established
mmddyyyy

1b Business Street Address
Mailing Address
City
1c County
1d Business Telephone
1e Type of Business

State

(

ZIP

)

3a
3b
3c
3d

Number of Employees
Monthly Gross Payroll
Frequency of Tax Deposits
1f Business Website (web address)
Is the business enrolled in Electronic
Federal Tax Payment System (EFTPS)
4
Does the business engage in e-Commerce (Internet sales) If yes, complete 5a and 5b.

Yes
Yes

No
No

PAYMENT PROCESSOR (e.g., PayPal, Authorize.net, Google Checkout, etc.) Include virtual currency wallet, exchange or digital currency exchange.
Name and Address (Street, City, State, ZIP code)

Payment Processor Account Number

5a
5b
CREDIT CARDS ACCEPTED BY THE BUSINESS
Type of Credit Card
Merchant Account Number
(e.g., Visa, Mastercard, etc.)

Issuing Bank Name and Address (Street, City, State, ZIP code)

6a

Phone

6b

Phone

6c

Phone

Section 2: Business Personnel and Contacts
PARTNERS, OFFICERS, LLC MEMBERS, MAJOR SHAREHOLDERS (Foreign and Domestic), ETC.
Taxpayer Identification Number
7a Full Name
)
Title
Home Telephone (
)
Home Address
Work/Cell Phone (
Ownership
Percentage
&
Shares
or Interest
City
State
ZIP
Responsible for Depositing Payroll Taxes
Yes
No
Annual Salary/Draw
Taxpayer Identification Number
7b Full Name
)
Title
Home Telephone (
)
Home Address
Work/Cell Phone (
Ownership Percentage & Shares or Interest
City
State
ZIP
Responsible for Depositing Payroll Taxes
Yes
No
Annual Salary/Draw
Taxpayer Identification Number
7c Full Name
)
Title
Home Telephone (
)
Home Address
Work/Cell Phone (
City
State
Responsible for Depositing Payroll Taxes

Yes

ZIP
No

7d Full Name
Title
Home Address
City
State
Responsible for Depositing Payroll Taxes

Yes

ZIP
No

Catalog Number 16649P

www.irs.gov

Ownership Percentage & Shares or Interest
Annual Salary/Draw
Taxpayer Identification Number
)
Home Telephone (
)
Work/Cell Phone (
Ownership Percentage & Shares or Interest
Annual Salary/Draw
Form 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)

Page

2

Section 3: Other Financial Information (Attach copies of all applicable documents)
8

Does the business use a Payroll Service Provider or Reporting Agent (If yes, answer the following)

Yes

Name and Address (Street, City, State, ZIP code)

9

Effective dates (mmddyyyy)

Is the business a party to a lawsuit (If yes, answer the following)
Plaintiff
Amount of Suit
$

10

Yes

Location of Filing

Represented by

Possible Completion Date (mmddyyyy)

Subject of Suit

Date Filed (mmddyyyy)

Docket/Case No.

Date Dismissed (mmddyyyy)

Yes

Date Discharged (mmddyyyy)

Petition No.

Date of Loan Current Balance As of

Name and Address (Street, City, State, ZIP code)

mmddyyyy

Yes

$

Have any assets been transferred, in the last 10 years, from this business for less than full value (If yes, answer the following)

13

Value at Time of Transfer
$

Date Transferred (mmddyyyy)

Yes

Related Business Name and Address (Street, City, State, ZIP code)

Yes

No

Related Business EIN:

Any increase/decrease in income anticipated (If yes, answer the following)

Yes
How much will it increase/decrease

Explain (Use attachment if needed)

No

To Whom or Where Transferred

Does this business have other business affiliations (e.g., subsidiary or parent companies) (If yes, answer the following)

14

No

Payment Date Payment Amount

$

List Asset

No

District of Filing

Do any related parties (e.g., officers, partners, employees) have outstanding amounts owed to the business (If yes, answer the following)

12

No

Defendant

Has the business ever filed bankruptcy (If yes, answer the following)

11

No

No

When will it increase/decrease

$
15

Is the business a Federal Government Contractor (Include Federal Government contracts in #18, Accounts/Notes Receivable)

Yes

No

Section 4: Business Asset and Liability Information (Foreign and Domestic)
16a

CASH ON HAND Include cash that is not in the bank

Total Cash on Hand

$

Contents
16b Is there a safe on the business premises

Yes

No

BUSINESS BANK ACOUNTS Include online and mobile accounts (e.g., PayPal), money market accounts, savings accounts, checking accounts
and stored value cards (e.g., payroll cards, government benefit cards, etc.)
List safe deposit boxes including location, box number and value of contents. Attach list of contents.
Type of
Account

Full Name and Address (Street, City, State, ZIP code) of
Bank, Savings & Loan, Credit Union or Financial Institution

Account Balance
Account Number

As of
mmddyyyy

17a

$

17b

$

17c

$

17d Total Cash in Banks (Add lines 17a through 17c and amounts from any attachments)

$

Catalog Number 16649P

www.irs.gov

Form 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)

Page

3

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.
Name & Address (Street, City, State, ZIP code)

Status (e.g., age,
factored, other)

Date Due
(mmddyyy)

Invoice Number or Government
Grant or Contract Number

Amount Due

18a

Contact Name
Phone
18b

$

Contact Name
Phone
18c

$

Contact Name
Phone
18d

$

Contact Name
Phone
18e

$

Contact Name
Phone

$

18f Outstanding Balance (Add lines 18a through 18e and amounts from any attachments)
$
INVESTMENTS List all investment assets below. Include stocks, bonds, mutual funds, stock options, certificates of deposit, commodities (e.g.,
gold, silver, copper, etc.) and virtual currency (e.g., Bitcoin, Ripple and Litecoin).
Name of Company & Address
(Street, City, State, ZIP code)

Used as collateral
on loan

Equity
Value Minus Loan

Loan Balance

Current Value

19a
Yes

No

Phone

$

$

$

$

$

$

19b
Yes
Phone

No

19c Total Investments (Add lines 19a, 19b, and amounts from any attachments)
AVAILABLE CREDIT Include all lines of credit and credit cards.

$
Available Credit

Amount Owed
Full Name & Address (Street, City, State, ZIP code)

Credit Limit

As of

As of

mmddyyyy

mmddyyyy

20a
Account No.

$

$

$

Account No.

$

$

$

20b

20c Total Credit Available (Add lines 20a, 20b, and amounts from any attachments)

Catalog Number 16649P

www.irs.gov

$

Form 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)

Page

4

REAL PROPERTY Include all real property and land contracts the business owns/leases/rents.
Purchase/
Lease Date
(mmddyyyy)

Current Fair
Market Value
(FMV)

Current Loan
Balance

Amount of
Monthly
Payment

Date of Final
Payment
(mmddyyyy)

Equity
FMV Minus Loan

21a Property Description
$
Location (Street, City, State, ZIP code) and County

$
$
$
Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and Phone

Phone
21b Property Description
$
Location (Street, City, State, ZIP code) and County

$
$
$
Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and Phone

Phone
21c Property Description
$
Location (Street, City, State, ZIP code) and County

$
$
$
Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and Phone

Phone
21d Property Description
$
Location (Street, City, State, ZIP code) and County

$
$
$
Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and Phone

Phone
21e Total Equity (Add lines 21a through 21d and amounts from any attachments)

$

VEHICLES, LEASED AND PURCHASED Include boats, RVs, motorcycles, all-terrain and off-road vehicles, trailers, mobile homes, etc.
Purchase/
Lease Date
(mmddyyyy)
22a Year
Mileage

Current Fair
Market Value
(FMV)

Current Loan
Balance

Amount of
Monthly
Payment

Date of Final
Payment
(mmddyyyy)

Equity
FMV Minus Loan

Make/Model
License/Tag Number

$
$
$
Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone

$

Vehicle Identification Number (VIN)
Phone
22b Year
Mileage

Make/Model
License/Tag Number

$
$
$
Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone

$

Vehicle Identification Number (VIN)
Phone
22c Year
Mileage

Make/Model
License/Tag Number

$
$
$
Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone

$

Vehicle Identification Number (VIN)
Phone
22d Year
Mileage

Make/Model
License/Tag Number

$
$
$
Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone

$

Vehicle Identification Number (VIN)
Phone
22e Total Equity (Add lines 22a through 22d and amounts from any attachments)

Catalog Number 16649P

www.irs.gov

$

Form 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)

Page

5

BUSINESS EQUIPMENT AND INTANGIBLE ASSETS Include all machinery, equipment, merchandise inventory, and other assets in 23a through 23d. List
intangible assets in 23e through 23g (licenses, patents, logos, domain names, trademarks, copyrights, software, mining claims, goodwill and trade secrets.)
Purchase/
Lease Date
(mmddyyyy)

Current Fair
Market Value
(FMV)

Current Loan
Balance

Amount of
Monthly
Payment

Date of Final
Payment
(mmddyyyy)

Equity
FMV Minus Loan

23a Asset Description
$
Location of asset (Street, City, State, ZIP code) and County

$
$
$
Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone

Phone
23b Asset Description
$
Location of asset (Street, City, State, ZIP code) and County

$
$
$
Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone

Phone
23c Asset Description
$
Location of asset (Street, City, State, ZIP code) and County

$
$
$
Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone

Phone
23d Asset Description
$
Location of asset (Street, City, State, ZIP code) and County

$
$
$
Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone

Phone
23e Intangible Asset Description
$
23f

Intangible Asset Description
$

23g Intangible Asset Description
$
23h Total Equity (Add lines 23a through 23g and amounts from any attachments)
BUSINESS LIABILITIES Include notes and judgements not listed previously on this form.
Business Liabilities
24a Description:

Secured/
Unsecured

Date Pledged
(mmddyyyy)

Date of Final
Payment
(mmddyyyy)

Payment
Amount

$

$

Phone
Secured
Unsecured

Name
Street Address
City/State/ZIP code

$

$

Phone

24c Total Payments (Add lines 24a and 24b and amounts from any attachments)

Catalog Number 16649P

Balance Owed

Secured
Unsecured

Name
Street Address
City/State/ZIP code
24b Description:

$

www.irs.gov

$

Form 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)

Page

6

Section 5: Monthly Income/Expenses Statement for Business
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.
Total Monthly Business Income
25
26
27
28
29

Income Source
Gross Receipts from Sales/Services
Gross Rental Income
Interest Income
Dividends
Cash Receipts (Not included in lines 25-28)
Other Income (Specify below)

30
31
32
33
34
35 Total Income (Add lines 25 through 34)

Total Monthly Business Expenses
Gross Monthly
36
37
38
39
40
41
42
43
44
45
46
47
48
49

$
$
$
$
$
$
$
$
$
$
$

Expense items
Materials Purchased 1
Inventory Purchased 2
Gross Wages & Salaries
Rent
Supplies 3
Utilities/Telephone 4
Vehicle Gasoline/Oil
Repairs & Maintenance
Insurance
Current Taxes 5
Other Expenses (Specify)
IRS Use Only-Allowable Installment Payments
Total Expenses (Add lines 36 through 47)
Net Income (Line 35 minus Line 48)

Actual Monthly
$
$
$
$
$
$
$
$
$
$
$
$
$
$

1 Materials Purchased: Materials are items directly related to the
production of a product or service.

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

2 Inventory Purchased: Goods bought for resale.

5 Current Taxes: Real estate, state, and local income tax, excise,
franchise, occupational, personal property, sales and the employer's
portion of employment taxes.

3 Supplies: Supplies are items used to conduct business and are
consumed or used up within one year. This could be the cost of
books, office supplies, professional equipment, etc.

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.
Signature

Title

Date

Print Name of Officer, Partner or LLC Member

After we review the completed Form 433-B, you may be asked to provide verification for the assets, encumbrances, income and expenses
reported. Documentation may include previously filed income tax returns, profit and loss statements, bank and investment statements, loan
statements, financing statements, bills or statements for recurring expenses, etc.
IRS USE ONLY (Notes)

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 16649P

www.irs.gov

Form 433-B (Rev. 2-2019)