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Department of the Treasury
Internal Revenue Service

Form 433-B
(February 2019)
Collection Information Statement for Businesses

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 ----
1b Business Street Address ----
Mailing Address ----
City ----
State ----
ZIP ----
1c County ----
1d Business Telephone ----
1e Type of Business ----
1f Business Website (web address) ----
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 ----
3a Number of Employees ----
3b Monthly Gross Payroll ----
3c Frequency of Tax Deposits ----
3d Is the business enrolled in Electronic Federal Tax Payment System (EFTPS) 
-- Yes
-- No
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.) Include virtual currency wallet, exchange or digital currency exchange.

5a
Name and Address (Street, City, State, ZIP code) ----
Payment Processor Account Number ----
5b
Name and Address (Street, City, State, ZIP code) ----
Payment Processor Account Number ----

CREDIT CARDS ACCEPTED BY THE BUSINESS

6a
Type of Credit Card (e.g., Visa, Mastercard, etc.) ----
Merchant Account Number ----
Issuing Bank Name and Address (Street, City, State, ZIP code) ----
Phone ----
6b
Type of Credit Card (e.g., Visa, Mastercard, etc.) ----
Merchant Account Number ----
Issuing Bank Name and Address (Street, City, State, ZIP code) ----
Phone ----
6c
Type of Credit Card (e.g., Visa, Mastercard, etc.) ----
Merchant Account Number ----
Issuing Bank Name and Address (Street, City, State, ZIP code) ----
Phone ----

Section 2: Business Personnel and Contacts

PARTNERS, OFFICERS, LLC MEMBERS, MAJOR SHAREHOLDERS (Foreign and Domestic), ETC.

7a
Full Name ----
Title ----
Home Address ----
City ----
State ----
ZIP ----
Responsible for Depositing Payroll Taxes
-- Yes
-- No
Taxpayer Identification 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
Taxpayer Identification 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
Taxpayer Identification 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
Taxpayer Identification Number ----
Home Telephone ----
Work/Cell Phone ----
Ownership Percentage & Shares or Interest ----
Annual Salary/Draw ----

Catalog Number 16649P
www.irs.gov
Form 433-B (Rev. 2-2019)

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Form 433-B (Rev. 2-2019)
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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) ----
Date Discharged (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 ----
Current Balance As of mmddyyyy ---- $ ----
Payment Date ----
Payment Amount $ ----
12 Have any assets been transferred, in the last 10 years, from this business 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 Name and Address (Street, City, State, ZIP code) ----
Related Business EIN: ----
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 ----
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 $ ----
16b Is there a safe on the business premises 
-- Yes
-- No
Contents ----

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.

17a
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 $ ----
17b
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 $ ----
17c
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 $ ----
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)

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Form 433-B (Rev. 2-2019)
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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.

18a Name & Address (Street, City, State, ZIP code) ----
Contact Name ----
Phone ----
Status (e.g., age, factored, other) ----
Date Due (mmddyyy) ----
Invoice Number or Government Grant or Contract Number ----
Amount Due $ ----
18b Name & Address (Street, City, State, ZIP code) ----
Contact Name ----
Phone ----
Status (e.g., age, factored, other) ----
Date Due (mmddyyy) ----
Invoice Number or Government Grant or Contract Number ----
Amount Due $ ----
18c Name & Address (Street, City, State, ZIP code) ----
Contact Name ----
Phone ----
Status (e.g., age, factored, other) ----
Date Due (mmddyyy) ----
Invoice Number or Government Grant or Contract Number ----
Amount Due $ ----
18d Name & Address (Street, City, State, ZIP code) ----
Contact Name ----
Phone ----
Status (e.g., age, factored, other) ----
Date Due (mmddyyy) ----
Invoice Number or Government Grant or Contract Number ----
Amount Due $ ----
18e Name & Address (Street, City, State, ZIP code) ----
Contact Name ----
Phone ----
Status (e.g., age, factored, other) ----
Date Due (mmddyyy) ----
Invoice Number or Government Grant or Contract Number ----
Amount Due $ ----
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).

19a Name of Company & Address (Street, City, State, ZIP code) ----
Phone ----
Used as collateral on loan
-- Yes
-- No
Current Value $ ----
Loan Balance $ ----
Equity Value Minus Loan $ ----
19b Name of Company & Address (Street, City, State, ZIP code) ----
Phone ----
Used as collateral on loan
-- Yes
-- No
Current Value $ ----
Loan Balance $ ----
Equity Value Minus Loan $ ----
19c Total Investments (Add lines 19a, 19b, and amounts from any attachments) $ ----

AVAILABLE CREDIT

Include all lines of credit and credit cards. 

20a Full Name & Address (Street, City, State, ZIP code) ----
Account No. ----
Credit Limit $ ----
Amount Owed As of ---- mmddyyyy $ ----
Available Credit As of ---- mmddyyyy $ ----
20b Full Name & Address (Street, City, State, ZIP code) ----
Account No. ----
Credit Limit $ ----
Amount Owed As of ---- mmddyyyy $ ----
Available Credit As of ---- mmddyyyy $ ----
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)

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Form 433-B (Rev. 2-2019)
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REAL PROPERTY

Include all real property and land contracts the business owns/leases/rents.

21a Property Description ----
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 $ ----
Location (Street, City, State, ZIP code) and County ----
Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and Phone ----
Phone ----

21b Property Description ----

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 $ ----
Location (Street, City, State, ZIP code) and County ----
Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and Phone ----
Phone ----21c Property Description ----
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 $ ----
Location (Street, City, State, ZIP code) and County ----
Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and Phone ----
Phone ----
21d Property Description ----
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 $ ----
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.

22a
Year ----
Make/Model ----
Mileage ----
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 ----
Make/Model ----
Mileage ----
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 ----
22c
Year ----
Make/Model ----
Mileage ----
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 ----
22d
Year ----
Make/Model ----
Mileage ----
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 ----
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)

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Form 433-B (Rev. 2-2019)
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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.)

23a Asset Description ----
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 $ ----
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 ----
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 $ ----
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 ----
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 $ ----
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 ----
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 $ ----
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 ----
Equity FMV Minus Loan $ ----
23f Intangible Asset Description ----
Equity FMV Minus Loan $ ----
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
-- Secured
-- Unsecured
Date Pledged (mmddyyyy) ----
Balance Owed $ ----
Date of Final Payment (mmddyyyy) ----
Payment Amount $ ----
Name ----
Street Address ----
City/State/ZIP code ----
Phone ----
24c Total Payments (Add lines 24a and 24b and amounts from any attachments) $ ----

Catalog Number 16649P
www.irs.gov
Form 433-B (Rev. 2-2019)

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Form 433-B (Rev. 2-2019)
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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

Income Source

25 Gross Receipts from Sales/Services
Gross Monthly $ ----
26 Gross Rental Income
Gross Monthly $ ----
27 Interest Income
Gross Monthly $ ----
28 Dividends
Gross Monthly $ ----
29 Cash Receipts (Not included in lines 25-28)
Gross Monthly $ ----

Other Income (Specify below)

30 ----
Gross Monthly $ ----
31 ----
Gross Monthly $ ----
32 ----
Gross Monthly $ ----
33 ----
Gross Monthly $ ----
34 ----
Gross Monthly $ ----
35 Total Income (Add lines 25 through 34)
Gross Monthly $ ----

Total Monthly Business Expenses

Expense items

36 Materials Purchased 1
Actual Monthly $ ----
37 Inventory Purchased 2
Actual Monthly $ ----
38 Gross Wages & Salaries
Actual Monthly $ ----
39 Rent
Actual Monthly $ ----
40 Supplies 3
Actual Monthly $ ----
41 Utilities/Telephone 4
Actual Monthly $ ----
42 Vehicle Gasoline/Oil
Actual Monthly $ ----
43 Repairs & Maintenance
Actual Monthly $ ----
44 Insurance
Actual Monthly $ ----
45 Current Taxes 5
Actual Monthly $ ----
46 Other Expenses (Specify)
Actual Monthly $ ----
47 IRS Use Only-Allowable Installment Payments
Actual Monthly $ shaded
48 Total Expenses (Add lines 36 through 47)
Actual Monthly $ shaded
49 Net Income (Line 35 minus Line 48) 
Actual Monthly $ shaded

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 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)
