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Item 21 – Real Property
List locations of all property that is leased, owned or Item 28 - Dividends
is being purchased by the business. If the business is Enter the amount of dividends received by the business
leasing or renting, list lessor or landlord. If the business is from U.S. and foreign sources.
purchasing, list lender. Include attachments if additional
space is needed. Item 29 – Cash Receipts
Include cash received from customers that is not included
Item 22 – Vehicles, Leased and Purchased in income items 25 through 28.
List all vehicles owned and leased (cars, boats, RVs,
motorcycles, all-terrain and off-road vehicles, trailers, Items 30 through 34 – Other Income
mobile homes, etc.). If the business is leasing, list the Other income represents items that do not fit into one of
lessor. If the business is purchasing, list the lender. Include the specific categories on Form 433-B or listed in other
attachments if additional space is needed. income on the business tax return.
For example:
Item 23 – Business Equipment and Intangible Assets
List all machinery, equipment, merchandise inventory, and • A construction company may have income from scrap
other assets in 23a through 23d. List intangible assets construction materials.
in 23e through 23g. Intangible assets include licenses, • A legal firm may have referral fees.
patents, logos, domain names, trademarks, copyrights, • A Medical Professional Corporation may have expert
software, mining claims, goodwill and trade secrets. witness fees associated with a trial.
Include attachments if additional space is needed.
Total Monthly Business Expenses
Item 24 - Business Liabilities Enter total monthly expenses for the business. Allowable
Include notes and judgments not listed previously on this business expenses are the cost of carrying on a business
form (e.g., if equipment is secured by a note and the note or trade. Generally, they must be necessary for the
was listed in Item 23, it would not be included in Item 24). operation of the business. Do not include “non-cash”
expenses, such as depreciation, bad debts or depletion.
Interest cannot be deducted as a separate expense if
Section 5 it is already included in any other allowable installment
Monthly Income/Expense Statement for payments.
Business
Attachments Required
Identify a time period that reflects your typical business Include attachments if additional space is needed to
income and expenses (e.g., 3, 6, 9 or 12 months). respond completely to any question. You may be asked
Complete the average monthly income/expense statement to provide additional verification after we review the
for the stated time period. The business information should completed Form 433-B.
reconcile with your business profit and loss statement.
Certification for Signature Line
Do not complete lines 47, 48 and 49 (For IRS use only). The partner, corporate officer, or LLC member must
sign Form 433-B, Collection Information Statement for
Total Monthly Business Income Businesses, under penalties of perjury. The signature
certifies that the information is accurate and complete. Any
Item 25 – Gross Receipts from Sales/Services changes made after signing the form should be initialed
Enter the amount of money received by the business and dated.
from all sources for the goods sold or services rendered.
This figure is the total before any costs or expenses are Distributions from Businesses
subtracted. Distributions from partnerships and subchapter S
corporations reported on Schedule K-1 and from limited
Item 26 – Gross Rental Income liability companies reported on Form 1040, Schedule C,
Enter the amount of gross rents which represent payments D, or E, should be included in the total distributions on
received for the use of business assets and may be in Line 25, page 4 of the Form 433-A, Collection Information
the form of monies, services, assets, bartering or any Statement for Wage Earners and Self-Employed
combination of these. Individuals.
Item 27 - Interest Income
Enter the amount of interest received by the business
from loans, notes, mortgages, bonds, bank deposits, tax
refunds, etc.
Publication 5059 (Rev. 5-2019) Catalog Number 60901W Department of the Treasury Internal Revenue Service www.irs.gov
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