Federal Free Printable Form 433-B (OIC) (Rev. January 2014) Catalog Number 55897B for 2017 Federal Collection Information Statement for Businesses

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Collection Information Statement for Businesses
Form 433-B (OIC) (Rev. January 2014) Catalog Number 55897B

Form Department of the Treasury — Internal Revenue Service 433-B (OIC) Collection Information Statement for Businesses (Rev. January 2014) Complete this form if your business is a Corporation Partnership Limited Liability Company (LLC) classified as a corporation 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 SelfEmployed Individuals. Other multi-owner/multi-member LLC Single member LLC Include attachments if additional space is needed to respond completely to any question. Section 1 Business Information 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 ( ) Mailing Address (if different from above or Post Office Box number) - Business website address Fax Number ( ) Federal Contractor Yes Does the business outsource its payroll processing and tax return preparation for a fee? Total Number of Employees Yes No If yes, list provider name and address in box below (Street, City, State, ZIP Code) No Frequency of Tax Deposits Average Gross Monthly Payroll $ 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 Title First Name Percent of Ownership and Annual Salary Social Security Number Primary Phone ( ) Secondary Phone - Last Name ( ) Title First Name Percent of Ownership and Annual Salary Social Security Number Primary Phone ( ) - ( ) Title First Name Percent of Ownership and Annual Salary Social Security Number Primary Phone ) Home Address (Street, City, State, ZIP Code) Secondary Phone Last Name ( Home Address (Street, City, State, ZIP Code) Home Address (Street, City, State, ZIP Code) Secondary Phone - 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 Bank Name Online Account Stored Value Card Account Number (1a) $ Checking Savings Money Market Online Account Bank Name Stored Value Card Account Number (1b) $ Checking Savings Money Market Online Account Bank Name Stored Value Card Account Number (1c) $ Investment Account: Stocks Bonds Total value of bank accounts from attachment (1d) $ Add lines (1a) through (1d) = (1) $ Other Name of Financial Institution Account Number Current Market Value Less Loan Balance = (2a) $ = (2b) $ Total of investment accounts from attachment. [current market value X.8 less loan balance(s)] (2c) $ Add lines (2a) through (2c) = (2) $ $ X .8 = $ Investment Account: Stocks – $ Bonds Other Name of Financial Institution Account Number Current Market Value $ Less Loan Balance X .8 = $ – $ 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 Yes Do you have accounts receivable, including e-payment, factoring companies, and any bartering or online auction accounts? 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 Property Description Date Purchased Name of Creditor Date of Final Payment Code) County and Country Current Market Value Less Loan Balance (Mortgages, etc.) $ X .8 = $ – $ Property Address (Street Address, City, State, ZIP Total Value of Real Estate = Property Description Date Purchased Name of Creditor Date of Final Payment (3a) $ Code) County and Country Less Loan Balance (Mortgages, etc.) Current Market Value X .8 = $ $ – $ 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 Lease Loan Year Monthly Lease/Loan Amount $ Vehicle Make & Model Date of Final Payment – $ Year Monthly Lease/Loan Amount Total value of vehicle (if the vehicle is leased, enter 0 as the total value) = Date Purchased Mileage or Use Hours Name of Creditor Date of Final Payment (4a) $ $ Less Loan Balance Current Market Value $ – $ X .8 = $ Vehicle Make & Model Loan Name of Creditor Less Loan Balance X .8 = $ Lease Mileage or Use Hours $ Current Market Value Lease Loan Date Purchased Year Monthly Lease/Loan Amount Total value of vehicle (if the vehicle is leased, enter 0 as the total value) = Date Purchased Mileage or Use Hours Name of Creditor Date of Final Payment (4b) $ $ Current Market Value $ X .8 = $ Less Loan Balance – $ Total value of vehicle (if the vehicle is leased, enter 0 as the total value) = Total value of vehicles listed from attachment [current market value X .8 less any loan balance(s)] Add lines (4a) through (4d) = Catalog Number 55897B www.irs.gov (4c) $ (4d) $ (4) $ 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 $ Total value of equipment Less Loan Balance X .8 = $ – $ (if leased or used in the production of income enter 0 as the total value) = Total value of equipment listed from attachment [current market value X .8 less any loan balance(s)] IRS allowed exemption for professional books and tools of trade - (5a) $ (5b) $ (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". Box A Available Equity in Assets Add lines (1) through (5) and enter the amount in Box A = $ 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) $ (10) $ Other income (Specify on attachment) Box B Total Business Income 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 = $ 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 (15) $ equipment, etc.) 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". Box C Total Business Expenses Add lines (11) through (20) and enter the amount in Box C = $ Round to the nearest dollar. Do not enter a negative number. If any line item is a negative number, enter "0". Box D Remaining Monthly Income Subtract Box C from Box B and enter the amount in Box D = $ 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 $ Box E Future Remaining Income X 12 = $ 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 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. Other Information Is the business currently in bankruptcy? Yes No Has the business ever filed bankruptcy? Yes No If yes, provide: Date Filed (mm/dd/yyyy) Petition No. Date Dismissed or Discharged (mm/dd/yyyy) 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: Does the business have any lines of credit? Yes No 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 Date (mm/dd/yyyy) Title 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)
Extracted from PDF file 2016-federal-form-433-b-oic.pdf, last modified February 2016

More about the Federal Form 433-B (OIC) Other TY 2016

We last updated the Collection Information Statement for Businesses in May 2017, so this is the latest version of Form 433-B (OIC), fully updated for tax year 2016. You can download or print current or past-year PDFs of Form 433-B (OIC) directly from TaxFormFinder. You can print other Federal tax forms here.


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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 (OIC) from the Internal Revenue Service in May 2017.

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Historical Past-Year Versions of Federal Form 433-B (OIC)

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


2016 Form 433-B (OIC)

Form 433-B (OIC) (Rev. January 2014) Catalog Number 55897B

Collection Information Statement for Businesses 2015 Form 433-B (OIC)

Form 433-B (OIC) (Rev. January 2014) Catalog Number 55897B

Collection Information Statement for Businesses 2012 Form 433-B (OIC)

Form 433-B (OIC) (Rev. May 2012)


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