Fillable F433b Accessible Form 433B (Rev. December 2012)

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F433b Accessible Form 433B (Rev. December 2012)

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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 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
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.) 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) 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
mmddyyyy
$
Current Balance As of
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 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
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
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.
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)
$
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
$
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 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 bartering or online auction accounts.
(List all contracts separately including contracts awarded, but not started). 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/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.
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 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
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 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
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 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)
Form 433-B (Rev. 12-2012)
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F433b Accessible Form 433B (Rev. December 2012)

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Completed 31 May 2020

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