IRS 433-B Collection Information Statement for Businesses Form

In the case of wanting to submit information related to a business to the IRS, the following form has to be used. Complete and submit the form and make sure not to leave any blank entry spaces.

Extracted Text for Proper Search

Form 	433-B	
(Rev. December 2012)
Department of the Treasury 
Internal Revenue Service	
Collection Information Statement for Businesses	
www.irs.gov	Cat. No. 16649P	Form 	433-B	 (Rev. 12-2012)	
Note: Complete all entry spaces with the current data available or "N/A" (not\
 applicable). Failure to complete all entry spaces may result in reject\
ion 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 
1b
Business Street Address
Mailing Address
City	State	 ZIP
1d 1c
Business Telephone	
(	)	
1e	Type of Business
1f
Business Website (web address)
County 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	
mmddyyyy	
3a	Number of Employees	
3b
3c	
Frequency of Tax Deposits 
3d   Is the business enrolled in Electronic 
Federal Tax Payment System (EFTPS) 	
Yes	No	
Monthly Gross Payroll 	
4	Does the business engage in e-Commerce (Internet sales) If yes, complete 5a and 5b.	Yes	No	
PAYMENT PROCESSOR (e.g., PayPal, Authorize.net, Google Checkout, etc.) Name and Address (Street, City, State, ZIP code)	Payment Processor Account Number	
5a
5b
CREDIT CARDS ACCEPTED BY THE BUSINESS	
Type of Credit Card  
(e.g., Visa, Mastercard, etc.) 	Merchant Account Number	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, ETC.
7a	
Full Name
Title
Home Address
City	State	 ZIP	
Responsible for Depositing Payroll Taxes	Yes	No	
Social Security Number
Home Telephone 	(	)	
Work/Cell Phone 	(	)	
Ownership Percentage & Shares or Interest
Annual Salary/Draw
7b	
Full Name
Title
Home Address
City	State	 ZIP	
Responsible for Depositing Payroll Taxes	Yes	No	
Social Security Number
Home Telephone 	(	)	
Work/Cell Phone 	(	)	
Ownership Percentage & Shares or Interest
Annual Salary/Draw
7c	
Full Name
Title
Home Address
City	State	 ZIP	
Responsible for Depositing Payroll Taxes	Yes	No	
Social Security Number
Home Telephone 	(	)	
Work/Cell Phone 	(	)	
Ownership Percentage & Shares or Interest
Annual Salary/Draw
7d	
Full Name
Title
Home Address
City	State	 ZIP
Responsible for Depositing Payroll Taxes	
Yes	No	
Social Security Number
Home Telephone 	(	)	
Work/Cell Phone 	(	)	
Ownership Percentage & Shares or Interest
Annual Salary/Draw
Date Incorporated/Established

Form 433-B (Rev. 12-2012)            Page  	2	
Form 	433-B	 (Rev. 12-2012)	
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	No
Name and Address (Street, City, State, ZIP code)	
Effective dates (mmddyyyy)	
9	Is the business a party to a lawsuit (If yes, answer the following)	Yes	No	
 Plaintiff	 Defendant	
Location of Filing	Represented by	Docket/Case No.	
Amount of Suit $	Possible Completion Date (mmddyyyy)	Subject of Suit	
10	Has the business ever filed bankruptcy (If yes, answer the following)	Yes	No	
Date Filed (mmddyyyy)	Date Dismissed (mmddyyyy)	Petition No.	District of Filing	
11	Do any related parties (e.g., officers, partners, employees) have outstanding amounts owed to the business  (If yes, answer the following)	Yes	No	
Name and Address (Street, City, State, ZIP code)	 Date of Loan	
mmddyyyy	
$
 Current Balance As of	 Payment DatePayment Amount
$	
12	Have any assets been transferred, in the last 10 years, from this busine\
ss for less than full value  (If yes, answer the following) 	Yes	No	
List Asset	Value at Time of Transfer
$	
 Date Transferred (mmddyyyy)	 To Whom or Where Transferred	
13	Does this business have other business affiliations (e.g., subsidiary or parent companies) (If yes, answer the following)	Yes	No	
 Related Business EIN:	Related Business Name and Address (Street, City, State, ZIP code)	
14	Any increase/decrease in income anticipated (If yes, answer the following)	Yes	No	
Explain (Use attachment if needed)	How much will it increase/decrease
$	
 When will it increase/decrease	
Section 4: Business Asset and Liability Information
16a	CASH ON HAND  Include cash that is not in the bank	$	
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 cont\
ents. 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 Number	
 Account Balance 
As of	
mmddyyyy	
17a	$ 	
17b	$ 	
17c	$ 	
17d	Total Cash in Banks (Add lines 17a through 17c and amounts from any attachments)	$	
Total Cash on Hand	
15	Is the business a Federal Government Contractor  (Include Federal Government contracts in #18, Accounts/Notes Receivable\
)	Yes	No	
16b	Is there a safe on the business premises 	Yes	No	
Contents	
Date Discharged (mmddyyyy)

Form 433-B (Rev. 12-2012)            Page  	3	
Form 	433-B	 (Rev. 12-2012)	
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	
$ 	
18eContact 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, s\
tock options, certificates of deposit and commodities  
(e.g., gold, silver, copper, etc.).
Name of Company & Address  
(Street, City, State, ZIP code)	Used as collateral  
on loan	Current Value	Loan Balance	Equity  
Value Minus Loan	
19a	
Phone	
Yes	No	
$ 	$ 	$ 	
19b	
Phone	
Yes	No	
$ 	$ 	$ 	
19c	Total Investments (Add lines 19a, 19b, and amounts from any attachments)	$	
Full Name & Address (Street, City, State, ZIP code)	Credit Limit	
Amount Owed 
As of	
mmddyyyy	
Available Credit 
As of	
mmddyyyy	
20a	
Account No.	$ 	$ 	$ 	
20b	
Account No.	$ 	$ 	$ 	
20c	Total Credit Available (Add lines 20a, 20b, and amounts from any attachments)	$	
ACCOUNTS/NOTES RECEIVABLE  Include e-payment accounts receivable and factoring companies, and any b\
artering or online auction accounts.   
(List all contracts separately including contracts awarded, but not sta\
rted).  Include Federal, state and local government grants and contracts.	
AVAILABLE CREDIT  Include all lines of credit and credit cards.

Form 433-B (Rev. 12-2012)            Page  	4	
REAL PROPERTY  Include all real property and land contracts the business owns/leases/re\
nts.	
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, trai\
lers, mobile homes, etc.
22a	Year
Mileage	
Make/Model
License/Tag Number	
Vehicle Identification Number (VIN)	
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	
$
Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone
Phone	
22b	Year
Mileage	
Make/Model
License/Tag Number	
Vehicle Identification Number (VIN)	
$	$	$	$
Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone
Phone	
22c	Year
Mileage	
Make/Model
License/Tag Number	
Vehicle Identification Number (VIN)	
$	$	$	$
Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone
Phone	
22d	Year
Mileage	
Make/Model
License/Tag Number	
Vehicle Identification Number (VIN)	
$	$	$	$
Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone
Phone	
22e	Total Equity (Add lines 22a through 22d and amounts from any attachments)	$
Form 	433-B	 (Rev. 12-2012)

Form 433-B (Rev. 12-2012)            Page  	5	
BUSINESS EQUIPMENT AND INTANGIBLE ASSETS  Include all machinery, equipment, merchandise inventory, and other asset\
s in 23a through 23d. List 
intangible assets in 23e through 23g (licenses, patents, logos, domain names, trademarks, copyrights, softwa\
re, 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
Secured
Unsecured	
 Date Pledged   (mmddyyyy) 	Balance Owed
$ 	
Date of Final  Payment 
(mmddyyyy)	Payment   Amount	
$ 	
Name
Street Address
City/State/ZIP code	Phone	24b	Description:	Secured
Unsecured	$ 	$ 	
Name
Street Address
City/State/ZIP code	Phone	
24c	Total Payments (Add lines 24a and 24b and amounts from any attachments)	$
Form 	433-B	 (Rev. 12-2012)

Form 433-B (Rev. 12-2012)            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 busin\
ess income and expenses.  
Income and Expenses during the period (mmddyyyy) to (mmddyyyy)
Provide a breakdown below of your average monthly income and expenses, b\
ased on the period of time used above.
Total Monthly Business Income	
Income Source	Gross Monthly	
25   Gross Receipts from Sales/Services	$ 	
26   Gross Rental Income	$ 	
27   Interest Income	$ 	
28   Dividends	$ 	
29   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
Expense items	Actual Monthly	
36   Materials Purchased 	1	$ 	
37   Inventory Purchased 	2	$	
38   Gross Wages & Salaries	$	
39   Rent	$	
40   Supplies 	3	$ 	
41   Utilities/Telephone 	4	$	
42   Vehicle Gasoline/Oil	$	
43   Repairs & Maintenance	$	
44   Insurance	$ 	
45   Current Taxes 	5	$	
46   Other Expenses (Specify)	$	
47   	IRS Use Only-Allowable Installment Payments	$	
48   Total Expenses (Add lines 36 through 47)	$	
49   Net Income (Line 35 minus Line 48) 	$
1 Materials Purchased: Materials are items directly related to the 
production of a product or service.
2 Inventory Purchased: Goods bought for resale.
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. 4 Utilities/Telephone: Utilities include gas, electricity, water, oil, other 
fuels, trash collection, telephone, cell phone and business internet.
5 Current Taxes: Real estate, state, and local income tax, excise, 
franchise, occupational, personal property, sales and the employer's 
portion of employment taxes.	
Certification:  Under penalties of perjury, I declare that to the best of my knowledge a\
nd 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 ve\
rification 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 expe\
nses, etc.
IRS USE ONLY (Notes)	
Form 	433-B	 (Rev. 12-2012)