Free Form 433-B (Rev. January 2008) - Federal

Form

433-B

(Rev. January 2008)
Department of the Treasury Internal Revenue Service

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 1c County 1d Business Telephone ( 1e Type of Business 1f Business Website
4

ZIP )

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 3b 3c 3d

Number of Employees Monthly Gross Payroll Frequency of Tax Deposits Is the business enrolled in Electronic Federal Tax Payment System (EFTPS)
No

Yes

No

Does the business engage in e-Commerce (Internet sales)

Yes

Payment Processor (e.g., PayPal, Authorize.net, Google Checkout, etc.), Name and Address (Street, Cty, 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 Merchant Account Provider Name and Address (Street, Cty, State, ZIP code)

6a

Phone

6b

Phone

6c Section 2: Business Personnel and Contacts Partners, Officers, LLC Members, Major Shareholders, Etc. 7a Full Name Title Home Address State City ZIP Yes No Responsible for Depositing Payroll Taxes 7b Full Name Title Home Address State ZIP City Yes No Responsible for Depositing Payroll Taxes 7c Full Name Title Home Address State ZIP City Yes No Responsible for Depositing Payroll Taxes 7d Full Name Title Home Address City State Responsible for Depositing Payroll Taxes
www.irs.gov

Phone

Social Security Number ) Home Telephone ( ( ) Work/Cell Phone Ownership Percentage & Shares or Interest Social Security Number ) Home Telephone ( ( ) Work/Cell Phone Ownership Percentage & Shares or Interest Social Security Number ) Home Telephone ( ( ) Work/Cell Phone Ownership Percentage & Shares or Interest Social Security Number ) Home Telephone ( ) ( Work/Cell Phone Ownership Percentage & Shares or Interest
Form

ZIP
Yes No
Cat. No. 16649P

433-B

(Rev. 1-2008)

Form 433-B (Rev. 1-2008)

Page

2

Section 3: Other Financial Information (Attach copies of all applicable documentation.) 8 Does the business use a Payroll Service Provider or Reporting Agent (If yes, answer the following) Name and Address (Street, City, State, ZIP code) Yes No

Effective dates (mmddyyyy)

9

Is the business a party to a lawsuit (If yes, answer the following) Location of Filing Plaintiff Defendant Amount of Suit $ Represented by

Yes

No

Docket/Case No.

Possible Completion Date (mmddyyyy)

Subject of Suit

10

Has the business ever filed bankruptcy (If yes, answer the following) Date Filed (mmddyyyy) Date Dismissed or Discharged (mmddyyyy) Petition No. Location

Yes

No

11

Do any related parties (e.g., officers, partners, employees) have outstanding amounts owed to the business (If yes, answer the following) Name and Address (Street, City, State, ZIP code) Date of Loan Current Balance As of
mmddyyyy

Yes

No

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) List Asset $ 13 Does this business have other business affiliations (e.g., subsidiary or parent companies) (If yes, answer the following) Related Business Name and Address (Street, City, State, ZIP code) Related Business EIN: Value at Time of Transfer Date Transferred (mmddyyyy)

Yes

No

To Whom or Where Transferred

Yes

No

14

Any increase/decrease in income anticipated (If yes, answer the following) Explain (use attachment if needed) $ Section 4: Business Asset and Liability Information How much will it increase/decrease

Yes

No

When will it increase/decrease

15

Cash on Hand. Include cash that is not in the bank

Total Cash on Hand

$

Business Bank Accounts. Include online bank accounts, 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 and 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

16a $ 16b $ 16c $ 16d Total Cash in Banks (Add lines 16a through 16c and amounts from any attachments) $
Form

433-B

(Rev. 1-2008)

Form 433-B (Rev. 1-2008)

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.)

17

Is the business a Federal Government Contractor
Status (e.g., age, factored, other)

Yes

No

(Include Federal Government contracts below)
Invoice Number or Federal Government Contract Number Amount Due

Accounts/Notes Receivable & Address (Street, City, State, ZIP code)

Date Due (mmddyyyy)

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, and certificates of deposit.
Name of Company & Address (Street, City, State, ZIP code) Used as collateral on loan Current Value Loan Balance Equity Value Minus Loan

19a Yes Phone: 19b Yes Phone: No $ $ $ $
Amount Owed As of
mmddyyyy

No $ $ $

19c Total Investments (Add lines 19a, 19b, and amounts from any attachments) Available Credit. Include all lines of credit and credit cards.
Full Name & Address (Street, City, State, ZIP code) of Credit Institution Credit Limit

Available Credit As of
mmddyyyy

20a

Account No. 20b

$

$

$

Account No.

$

$

$ $
Form

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

433-B

(Rev. 1-2008)

Form 433-B (Rev. 1-2008)

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

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

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

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

21e Total Equity (Add lines 21a through 21d and amounts from any attachments) Vehicles, Leased and Purchased. Include boats, RVs, motorcycles, trailers, mobile homes, etc.
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

22a Year Make

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

22b Year Make

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

22c Year Make

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

22d Year Make

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

22e Total Equity (Add lines 22a through 22d and amounts from any attachments)
Form

$

433-B

(Rev. 1-2008)

Form 433-B (Rev. 1-2008)

Page

5

Business Equipment. Include all machinery, equipment, merchandise inventory, and/or other assets. Include Uniform Commercial Code (UCC) filings.
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

23b Asset Description $ Location of asset (Street, City, State, ZIP code) and County $ $ $ Lender/Lessor Name, Address, (Street, City, State, ZIP code) and 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

23d Asset Description $ Location of asset (Street, City, State, ZIP code) and County $ $ $ Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone

23e Total Equity (Add lines 23a through 23d and amounts from any attachments) Business Liabilities. Include notes and judgments below.
Business Liabilities Secured/ Unsecured Date Pledged (mmddyyyy) Balance Owed Date of Final Payment (mmddyyyy)

$
Payment Amount

24a Description:

Secured Unsecured $ $

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

Phone: Secured Unsecured $ $

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

Phone: Secured Unsecured $ $

Name Street Address City/State/ZIP code 24d Total Payments (Add lines 24a through 24c and amounts from any attachments)

Phone: $
Form

433-B

(Rev. 1-2008)

Form 433-B (Rev. 1-2008)

Page

6

Section 5: Monthly Income/Expense Statement for Business
Accounting Method Used: Cash Accrual Income and Expenses during the period (mmddyyyy)
Total Monthly Business Income Source Gross Monthly

to (mmddyyyy)
Expense Items

.
Actual Monthly

Total Monthly Business Expenses

25 26 27 28 29 30 31 32 33 34 35

Gross Receipts from Sales/Services Gross Rental Income Interest Income Dividends Cash Other Income (Specify below)

$ $ $ $ $ $ $ $ $ $

Total Income (Add lines 25 through 34)

36 37 38 39 40 41 42 43 44 45 46 47 48

Materials Purchased1 Inventory Purchased2 Gross Wages & Salaries Rent Supplies3 Utilities/Telephone4 Vehicle Gasoline/Oil Repairs & Maintenance Insurance Current Taxes5 Other Expenses (Specify) IRS Use Only Allowable Installment Payments Total Expenses (Add lines 36 through 47)

$ $ $ $ $ $ $ $ $ $ $ $ $

$

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.

1

4

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

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

Attachments Required: Copies of the following items for the last 3 months from the date this form is submitted (check all attached items):
Banks and Investments - Statements for all money market, brokerage, checking/savings accounts, certificates of deposit, stocks/bonds. Assets - Statements from lenders on loans, monthly payments, payoffs, and balances, for all assets. Include copies of UCC financing statements and accountant's depreciation schedules. Expenses - Bills or statements for monthly recurring expenses of utilities, rent, insurance, property taxes, telephone and cell phone, insurance premiums, court orders requiring payments, other expenses. Other - credit card statements, profit and loss statements, all loan payoffs, etc. Copy of the last income tax return filed; Form 1120, 1120S, 1065, 1040, 990, etc. Additional information or proof may be subsequently requested.

FINANCIAL ANALYSIS OF COLLECTION POTENTIAL FOR BUSINESSES Cash Available (Lines 15, 16d, 18f, 19c, and 20c) Distrainable Asset Summary (Lines 21e, 22e, and 23e)

(IRS USE ONLY) $

Total Cash

$ Total Equity Monthly Income Minus Expenses (Line 35 Minus Line 48) Monthly Available Cash $ 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.
Form

433-B

(Rev. 1-2008)