×
tax forms found in
Tax Form Code
Tax Form Name

Federal Free Printable Form 433B (Rev. December 2012) for 2019 Federal Collection Information Statement for Businesses

It appears you don't have a PDF plugin for this browser. Please use the link below to download 2018-federal-form-433-b.pdf, and you can print it directly from your computer.

Collection Information Statement for Businesses
Form 433B (Rev. December 2012)

Form 433-B Collection Information Statement for Businesses (Rev. December 2012) Department of the Treasury Internal Revenue Service 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 2a Employer Identification No. (EIN) 1b Business Street Address 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 Mailing Address City 1c County 1d Business Telephone 1e Type of Business State ZIP 2c Date Incorporated/Established mmddyyyy ( ) 3a Number of Employees 3b Monthly Gross Payroll 3c Frequency of Tax Deposits 1f Business Website (web address) 4 3d Is the business enrolled in Electronic Federal Tax Payment System (EFTPS) Does the business engage in e-Commerce (Internet sales) If yes, complete 5a and 5b. Yes No 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 Responsible for Depositing Payroll Taxes Yes ZIP No 7b Full Name Title Home Address City State Responsible for Depositing Payroll Taxes Yes ZIP No ZIP No 7d Full Name Title Home Address City State Responsible for Depositing Payroll Taxes www.irs.gov ZIP No Cat. No. 16649P ) ) Ownership Percentage & Shares or Interest Annual Salary/Draw Social Security Number Home Telephone ( Work/Cell Phone ( Yes ) ) Work/Cell Phone ( Ownership Percentage & Shares or Interest Annual Salary/Draw Social Security Number Home Telephone ( Work/Cell Phone ( Yes ) ) Ownership Percentage & Shares or Interest Annual Salary/Draw Social Security Number Home Telephone ( 7c Full Name Title Home Address City State Responsible for Depositing Payroll Taxes Social Security Number Home Telephone ( Work/Cell Phone ( ) ) Ownership Percentage & Shares or Interest Annual Salary/Draw Form 433-B (Rev. 12-2012) Form 433-B (Rev. 12-2012) Page 2 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 Effective dates (mmddyyyy) Name and Address (Street, City, State, ZIP code) 9 Is the business a party to a lawsuit (If yes, answer the following) Plaintiff Amount of Suit No Yes Location of Filing Represented by Possible Completion Date (mmddyyyy) Subject of Suit No Docket/Case No. Defendant $ 10 Has the business ever filed bankruptcy (If yes, answer the following) Date Filed (mmddyyyy) 11 Date Dismissed (mmddyyyy) Yes Date Discharged (mmddyyyy) Petition No. District of Filing Yes 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 No No Payment Date Payment Amount mmddyyyy $ $ 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 Value at Time of Transfer Date Transferred (mmddyyyy) Yes No To Whom or Where Transferred $ 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) 14 Yes Related Business EIN: Any increase/decrease in income anticipated (If yes, answer the following) Yes How much will it increase/decrease Explain (Use attachment if needed) No No 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 $ Contents 16b Is there a safe on the business premises Yes No 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 Balance Account Number 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) Form 433-B (Rev. 12-2012) 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). Include Federal, state and local government grants and contracts. 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 Equity Value Minus Loan Loan Balance Current Value 19a Yes No Phone $ $ $ $ $ $ 19b Yes Phone No 19c Total Investments (Add lines 19a, 19b, and amounts from any attachments) $ AVAILABLE CREDIT Include all lines of credit and credit cards. Available Credit Amount Owed Full Name & Address (Street, City, State, ZIP code) Credit Limit As of As of mmddyyyy mmddyyyy 20a Account No. $ $ $ Account No. $ $ $ 20b 20c Total Credit Available (Add lines 20a, 20b, and amounts from any attachments) $ Form 433-B (Rev. 12-2012) 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. Purchase/ Lease Date (mmddyyyy) 22a Year Mileage Current Fair Market Value (FMV) Current Loan Balance Amount of Monthly Payment Date of Final Payment (mmddyyyy) Equity FMV Minus Loan Make/Model License/Tag Number $ $ $ Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone $ Vehicle Identification Number (VIN) Phone 22b Year Mileage Make/Model License/Tag Number $ $ $ Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone $ Vehicle Identification Number (VIN) Phone 22c Year Mileage Make/Model License/Tag Number $ $ $ Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone $ Vehicle Identification Number (VIN) Phone 22d Year Mileage Make/Model License/Tag Number $ $ $ Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone $ Vehicle Identification Number (VIN) 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 Date Pledged (mmddyyyy) $ Balance Owed Date of Final Payment (mmddyyyy) Payment Amount Secured Unsecured $ $ Name Street Address City/State/ZIP code 24b Description: Phone Secured Unsecured $ $ Name Street Address City/State/ZIP code 24c Total Payments (Add lines 24a and 24b and amounts from any attachments) Phone $ 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 Expenses Total Monthly Business Income Income Source 25 Gross Receipts from Sales/Services $ Gross Monthly Expense items 36 Materials Purchased 1 $ 26 Gross Rental Income 27 Interest Income 28 Dividends $ $ $ 37 Inventory Purchased 2 38 Gross Wages & Salaries 39 Rent $ $ $ 29 Cash Receipts (Not included in lines 25-28) Other Income (Specify below) 30 $ $ 40 Supplies 3 41 Utilities/Telephone 4 42 Vehicle Gasoline/Oil $ $ $ 31 32 33 $ $ $ 43 Repairs & Maintenance 44 Insurance 45 Current Taxes 5 $ $ $ 34 35 Total Income (Add lines 25 through 34) $ $ 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) $ Actual Monthly 1 Materials Purchased: Materials are items directly related to the production of a product or service. 4 Utilities/Telephone: Utilities include gas, electricity, water, oil, other fuels, trash collection, telephone, cell phone and business internet. 2 Inventory Purchased: Goods bought for resale. 5 Current Taxes: Real estate, state, and local income tax, excise, franchise, occupational, personal property, sales and the employer's portion of employment taxes. 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. 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)
Extracted from PDF file 2018-federal-form-433-b.pdf, last modified October 2009

More about the Federal Form 433-B Other TY 2018

We last updated the Collection Information Statement for Businesses in February 2019, so this is the latest version of Form 433-B, fully updated for tax year 2018. You can download or print current or past-year PDFs of Form 433-B directly from TaxFormFinder. You can print other Federal tax forms here.

Related Federal Other Forms:

TaxFormFinder has an additional 774 Federal income tax forms that you may need, plus all federal income tax forms. These related forms may also be needed with the Federal Form 433-B.

Form Code Form Name
Form 433-B (OIC) Collection Information Statement for Businesses

Download all  tax forms View all 775 Federal Income Tax Forms


Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 433-B from the Internal Revenue Service in February 2019.

Show Sources >

Historical Past-Year Versions of Federal Form 433-B

We have a total of six past-year versions of Form 433-B in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2018 Form 433-B

Form 433B (Rev. December 2012)

2017 Form 433-B

Form 433B (Rev. December 2012)

2016 Form 433-B

Form 433B (Rev. December 2012)

Collection Information Statement for Businesses 2015 Form 433-B

Form 433B (Rev. December 2012)

Collection Information Statement for Businesses 2012 Form 433-B

Form 433B (Rev. December 2012)

Collection Information Statement for Businesses 2011 Form 433-B

Form 433-B (Rev. January 2008)


TaxFormFinder Disclaimer:

While we do our best to keep our list of Federal Income Tax Forms up to date and complete, we cannot be held liable for errors or omissions. Is the form on this page out-of-date or not working? Please let us know and we will fix it ASAP.

** This Document Provided By TaxFormFinder.org **
Source: http://www.taxformfinder.org/federal/form-433-b