Fillable Printable Collection Information Statement for Businesses Form
Fillable Printable Collection Information Statement for Businesses Form
Collection Information Statement for Businesses Form
Form 433-B (OIC)
(Rev. January 2014)
Department of the Treasury — Internal Revenue Service
Collection Information Statement for Businesses
Complete this form if your business is a
Corporation
Partnership
Limited Liability Company (LLC) classified as a corporation
Other multi-owner/multi-member LLC
Single member LLC
If your business is a sole proprietorship (filing Schedule C, D, E, F,
etc.), do not use this form. Instead, complete Form 433-A (OIC)
Collection Information Statement for Wage Earners and Self-
Employed Individuals.
Include attachments if additional space is needed to respond completely to any question.
Business InformationSection 1
Business Name Employer Identification Number
Business Address (street, city, state, zip code)
County of Business Location
Description of Business and dba or "Trade Name"
Primary Phone
( )
-
Secondary Phone
( )
-
Business website address
Mailing Address
(if different from above or Post Office Box number)
Fax Number
( ) -
Federal Contractor
Yes No
Total Number of Employees
Frequency of Tax Deposits Average Gross Monthly Payroll
$
Does the business outsource its payroll processing and tax
return preparation for a fee?
Yes No
If yes, list provider name and address in box below
(Street, City, State, ZIP Code)
Provide information about all partners, officers, LLC members, major shareholders (foreign and domestic), etc., associated with the
business. Include attachments if additional space is needed.
Last Name First Name
Title
Percent of Ownership and Annual Salary
Social Security Number
Primary Phone
( ) -
Secondary Phone
( ) -
Home Address
(Street, City, State, ZIP Code)
Last Name First Name
Title
Percent of Ownership and Annual Salary
Social Security Number
Primary Phone
( ) -
Secondary Phone
( ) -
Home Address
(Street, City, State, ZIP Code)
Last Name First Name
Title
Percent of Ownership and Annual Salary
Social Security Number
Primary Phone
( ) -
Secondary Phone
( ) -
Home Address
(Street, City, State, ZIP Code)
Catalog Number 55897B
www.irs.gov
Form
433-B (OIC) (Rev. 1-2014)
Page 2 of 6
Section 2
Business Asset Information
Gather the most current statement from banks, lenders on loans, mortgages (including second mortgages), monthly payments, loan balances, and
accountant's depreciation schedules, if applicable. Also, include make/model/year/mileage of vehicles and current value of business assets. To
estimate the current value, you may consult resources like Kelley Blue Book (www.kbb.com), NADA (www.nada.com), local real estate postings of
properties similar to yours, and any other websites or publications that show what the business assets would be worth if you were to sell them. Asset
value is subject to adjustment by IRS. Enter the total amount available for each of the following (if additional space is needed, please include attachments).
Round to the nearest dollar. Do not enter a negative number. If any line item is a negative number, enter "0".
Cash Checking Savings Money Market Online Account Stored Value Card
Bank Name Account Number
(1a) $
Checking Savings Money Market Online Account Stored Value Card
Bank Name Account Number
(1b) $
Checking Savings Money Market Online Account Stored Value Card
Bank Name Account Number
(1c) $
Total value of bank accounts from attachment
(1d) $
Add lines (1a) through (1d) =
(1) $
Investment Account:
Stocks Bonds Other
Name of Financial Institution Account Number
Current Market Value
$ X .8 = $
Less Loan Balance
– $ =
(2a) $
Investment Account:
Stocks Bonds Other
Name of Financial Institution Account Number
Current Market Value
$ X .8 = $
Less Loan Balance
– $ =
(2b) $
Total of investment accounts from attachment. [current market value X.8 less loan balance(s)]
(2c) $
Add lines (2a) through (2c) =
(2) $
Notes Receivable
Do you have notes receivable?
Yes No
If yes, attach current listing which includes name, age, and amount of note(s) receivable.
Accounts Receivable
Do you have accounts receivable, including e-payment, factoring
companies, and any bartering or online auction accounts?
Yes No
If yes, you may be asked to provide a list of name, age, and amount of the account(s) receivable.
Catalog Number 55897B
www.irs.gov
Form
433-B (OIC) (Rev. 1-2014)
Page 3 of 6
Section 2 (Continued)
Business Asset Information
If the business owns more properties, vehicles, or equipment than shown in this form, please list on an attachment.
Real Estate
(Buildings, Lots, Commercial Property, etc.)
Property Address (Street Address, City, State, ZIP
Code)
Property Description
Date Purchased
Name of Creditor
Date of Final Payment
County and Country
Current Market Value
$
X .8 = $
Less Loan Balance (Mortgages, etc.)
– $
Total Value of Real Estate = (3a) $
Property Address
(Street Address, City, State, ZIP
Code)
Property Description Date Purchased
Name of Creditor Date of Final Payment
County and Country
Current Market Value
$
X .8 = $
Less Loan Balance (Mortgages, etc.)
– $
Total Value of Real Estate = (3b) $
Total value of property(s) listed from attachment [current market value X .8 less any loan balance(s)]
(3c) $
Add lines (3a) through (3c) =
(3) $
Business Vehicles (cars, boats, motorcycles, trailers, etc.). If additional space is needed, list on an attachment.
Vehicle Make & Model
Year
Date Purchased Mileage or Use Hours
Lease
Loan
Monthly Lease/Loan Amount
$
Name of Creditor Date of Final Payment
Current Market Value
$
X .8 = $
Less Loan Balance
– $
Total value of vehicle (if the vehicle
is leased, enter 0 as the total value) =
(4a) $
Vehicle Make & Model
Year Date Purchased Mileage or Use Hours
Lease
Loan
Monthly Lease/Loan Amount
$
Name of Creditor Date of Final Payment
Current Market Value
$
X .8 = $
Less Loan Balance
– $
Total value of vehicle (if the vehicle
is leased, enter 0 as the total value) =
(4b) $
Vehicle Make & Model Year Date Purchased Mileage or Use Hours
Loan
Lease
Monthly Lease/Loan Amount
$
Name of Creditor Date of Final Payment
Current Market Value
$
X .8 = $
Less Loan Balance
– $
Total value of vehicle (if the vehicle
is leased, enter 0 as the total value) =
(4c) $
Total value of vehicles listed from attachment [current market value X .8 less any loan balance(s)]
(4d) $
Add lines (4a) through (4d) =
(4) $
Catalog Number 55897B
www.irs.gov
Form
433-B (OIC) (Rev. 1-2014)
Page 4 of 6
Section 2 (Continued)
Business Asset Information
Other Business Equipment
[If you have more than one piece of equipment, please list on a separate attachment and put the total of all equipment in box (5b)]
Type of equipment
Current Market Value
$ X .8 = $
Less Loan Balance
– $
Total value of equipment
(if leased or used in the production of
income enter 0 as the total value)
=
(5a) $
Total value of equipment listed from attachment [current market value X .8 less any loan balance(s)]
(5b) $
IRS allowed exemption for professional books and tools of trade -
(5c) $ [4,470]
Total value of all business equipment =
Add lines (5a) and (5b) minus line (5c), if number is less than zero, enter zero =
(5) $
Do not include amount on the lines with a letter beside the number. Round to the nearest dollar.
Do not enter a negative number. If any line item is a negative number, enter "0".
Add lines (1) through (5) and enter the amount in Box A =
$
Box A
Available Equity in Assets
Section 3
Business Income Information
Enter the average gross monthly income of your business. To determine your gross monthly income use the most recent 6-12 months documentation
of commissions, invoices, gross receipts from sales/services, etc.; most recent 6-12 months earnings statements, etc., from every other source of
income (such as rental income, interest and dividends, or subsidies); or you may use the most recent 6-12 months Profit and Loss (P&L) to provide the
information of income and expenses.
Note: If you provide a current profit and loss statement for the information below, enter the total gross monthly income in Box B below. Do
not complete lines (6) - (10).
Gross receipts (6) $
Gross rental income (7) $
Interest income (8) $
Dividends (9) $
Other income (Specify on attachment)
(10) $
Round to the nearest dollar.
Do not enter a negative number. If any line item is a negative number, enter "0".
Add lines (6) through (10) and enter the amount in Box B =
$
Box B
Total Business Income
Section 4
Business Expense Information
Enter the average gross monthly expenses for your business using your most recent 6-12 months statements, bills, receipts, or other documents
showing monthly recurring expenses.
Note: If you provide a current profit and loss statement for the information below, enter the total monthly expenses in Box C below. Do not
complete lines (11) - (20).
Materials purchased (e.g., items directly related to the production of a product or service)
(11) $
Inventory purchased (e.g., goods bought for resale)
(12) $
Gross wages and salaries (13) $
Rent (14) $
Supplies (items used to conduct business and used up within one year, e.g., books, office supplies, professional
equipment, etc.)
(15) $
Utilities/telephones (16) $
Vehicle costs (gas, oil, repairs, maintenance)
(17) $
Insurance (other than life)
(18) $
Current taxes (e.g., real estate, state, and local income tax, excise franchise, occupational, personal property,
sales and employer's portion of employment taxes, etc.)
(19) $
Other expenses (e.g., secured debt payments. Specify on attachment. Do not include credit card payments)
(20) $
Round to the nearest dollar.
Do not enter a negative number. If any line item is a negative number, enter "0".
Add lines (11) through (20) and enter the amount in Box C =
$
Box C
Total Business Expenses
Round to the nearest dollar.
Do not enter a negative number. If any line item is a negative number, enter "0".
Subtract Box C from Box B and enter the amount in Box D =
$
Box D
Remaining Monthly Income
Catalog Number 55897B
www.irs.gov
Form
433-B (OIC) (Rev. 1-2014)
Page 5 of 6
Section 5
Calculate Your Minimum Offer Amount
The next steps calculate your minimum offer amount. The amount of time you take to pay your offer in full will affect your minimum offer amount.
Paying over a shorter period of time will result in a smaller minimum offer amount.
If you will pay your offer in 5 months or less, multiply "Remaining Monthly Income" (Box D) by 12 to get "Future Remaining Income." Do not enter a
number less than zero.
$
Round to the nearest whole dollar.
Enter the amount from Box D
X 12 =
$
Box E Future Remaining Income
If you will pay your offer in more than 5 months, multiply "Remaining Monthly Income" (from Box D) by 24 to get "Future Remaining Income." Do not
enter a number less than zero.
$
Enter the amount from Box D
X 24 =
$
Box F Future Remaining Income
Determine your minimum offer amount by adding the total available assets from Box A to amount in either Box E or Box F. Your offer amount must
be more than zero.
$
Enter the amount from Box A*
+
$
Enter the amount from either
Box E or Box F
=
$
Offer Amount
Your offer must be more than zero ($0).
Do not leave blank. Use whole dollars only.
If you cannot pay the offer amount due to special circumstances, explain on the Form 656, Offer in Compromise, Section 3. You must offer
something.
*You may exclude any equity in income producing assets shown in Section 2 of this form.
Section 6 Other Information
Additional information IRS needs to
consider settlement of your tax debt. If this
business is currently in a bankruptcy
proceeding, the business is not eligible to
apply for an offer.
Is the business currently in bankruptcy?
Yes No
Has the business ever filed bankruptcy?
Yes No
If yes, provide:
Date Filed
(mm/dd/yyyy) Date Dismissed or Discharged (mm/dd/yyyy)
Petition No. Location Filed
Does this business have other business affiliations (e.g., subsidiary or parent companies)?
Yes No
If yes, list the Name and Employer Identification Number:
Do any related parties (e.g., partners, officers, employees) owe money to the business?
Yes No
Is the business currently, or in the past, a party to a lawsuit?
Yes No
If yes, date the lawsuit was resolved:
In the past 10 years, has the business transferred any assets for less than their full value?
Yes No
If yes, provide date and type of asset transferred:
Has the business been located outside the U.S. for 6 months or longer in the past 10 years?
Yes No
Does the business have any funds being held in trust by a third party?
Yes No
If yes, how much $ Where:
Yes No
Does the business have any lines of credit?
If yes, credit limit $ Amount owed $
What property secures the line of credit?
Catalog Number 55897B
www.irs.gov
Form
433-B (OIC) (Rev. 1-2014)
Page 6 of 6
Section 7 Signatures
Under penalties of perjury, I declare that I have examined this offer, including accompanying documents, and to the best of my knowledge
it is true, correct, and complete.
Signature of Taxpayer
Title
Date
(mm/dd/yyyy)
Remember to include all applicable attachments from list below.
A current Profit and Loss statement covering at least the most recent 6-12 month period, if appropriate.
Copies of the three most recent statements for each bank, investment, and retirement account.
If an asset is used as collateral on a loan, include copies of the most recent statement from lender(s) on loans, monthly
payments, loan payoffs, and balances.
Copies of the most recent statement of outstanding notes receivable.
Copies of the most recent statements from lenders on loans, mortgages (including second mortgages), monthly payments,
loan payoffs, and balances.
Copies of relevant supporting documentation of the special circumstances described in the "Explanation of Circumstances"
on Form 656, if applicable.
Attach a Form 2848, Power of Attorney, if you would like your attorney, CPA, or enrolled agent to represent you and you
do not have a current form on file with the IRS.
Catalog Number 55897B
www.irs.gov
Form
433-B (OIC) (Rev. 1-2014)
