Catalog Number 16649P www.irs.gov
Form
433-B (Rev. 2-2019)
Form 433-B (Rev. 2-2019) Page 6
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.
Section 5: Monthly Income/Expenses Statement for Business
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.