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How to prepare a

Collection Information Statement (Form 433-B)

Who should use Form 433-B? Section 4 Business Asset and Liability
Information
Form 433-B is used to obtain current financial information
necessary for determining how a business can satisfy an Item 16 – Cash on Hand
outstanding tax liability. Enter the amount of cash on hand which includes cash in a
safe, cash register and petty cash.
The following business entities need to complete
Form 433-B: If the business has a safe, list the contents.
• Partnerships
• Corporations Items 17 –Business Bank Accounts
• Exempt Organizations Enter all accounts, even if there is currently no balance.
• S Corporations Include online bank accounts, money market accounts,
• Limited Liability Companies (LLC) classified as a corporation savings accounts, checking accounts, mobile payment
• Other LLCs accounts and stored value cards such as a payroll cards and
government benefit cards. Also, list all safety deposit boxes
including location, box number and value. Attach a list of
Section 1 contents. Do not enter bank loans.

Business Information
Item 18 – Accounts/Notes Receivable
Enter the name, address and phone number of the receivable.
Complete items 1 through 6. For items 4 and 5, include Include e-payment accounts and factoring companies, as well
information for mobile commerce and mobile accounts such as as any bartering or online auction accounts. Include Federal
PayPal Mobile or Paymate. Answer all questions in this section Government Contracts. List all contracts separately, including
or write N/A if a question is not applicable. Include attachments contracts awarded, but not started. Include attachments if
if additional space is needed to respond completely to any additional space is needed.
question.
Item 19 – Investments
Include any investments including stocks, bonds, mutual funds,
stock options, certificates of deposit, and commodities such as
gold, silver, copper, etc.
Section 2
Business Personnel and Contacts Item 20 – Available Credit
Include all lines of credit and credit cards issued by a bank,
Enter information about all persons responsible for collecting, credit union, or savings and loan (MasterCard, Visa, overdraft
paying and depositing withheld income and employment taxes, protection, etc.).
or for paying collected excise taxes. These persons could be
officers, employees, partners, major shareholders, etc. Include Items 21, 22 and 23 – Real Property, Vehicles and
attachments if additional space is needed to respond Business Equipment and Intangible Assets
completely to the question.
Current Fair Market Value – Indicate the amount you could
sell the asset for today.

Section 3 Date of Final Payment – Enter the date the loan or lease will
be fully paid.
Other Financial Information
Item 21 – Real Property
Complete items 8 through 15 and attach copies of all List locations of all property that is leased, owned or is being
applicable documentation. Answer all questions in this section purchased by the business. If the business is leasing or
or write N/A if a question is not applicable. Include attachments renting, list lessor or landlord. If the business is purchasing,
if additional space is needed to respond completely to any list lender. Include attachments if additional space is needed.
question.
Item 22 – Vehicles, Leased and Purchased
List all vehicles owned and leased (cars, boats, RVs,
motorcycles, all-terrain and off-road vehicles, trailers, mobile
homes, etc.). If the business is leasing, list the lessor. If the
business is purchasing, list the lender. Include attachments if
additional space is needed.

Publication 5059 (12-2012) Catalog Number 60901W Department of the Treasury Internal Revenue Service www.irs.gov

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Item 23 – Business Equipment and Intangible Assets Items 30 through 34 – Other Income
List all machinery, equipment, merchandise inventory, and Other income represents items that do not fit into one of the
other assets in 23a through 23d. List intangible assets in 23e specific categories on Form 433-B or listed in other income on
through 23g. Intangible assets include licenses, patents, logos, the business tax return.
domain names, trademarks, copyrights, software, mining For example:
claims, goodwill and trade secrets. Include attachments if • A construction company may have income from scrap
additional space is needed. construction materials.
• A legal firm may have referral fees.
Item 24 - Business Liabilities • A Medical Professional Corporation may have expert
Include notes and judgments not listed previously on this form witness fees associated with a trial.
(e.g., if equipment is secured by a note and the note was listed
in Item 23, it would not be included in Item 24). Total Monthly Business Expenses
Enter total monthly expenses for the business. Allowable
business expenses are the cost of carrying on a business or
trade. Generally, they must be necessary for the operation of
Section 5 the business. Do not include "non-cash" expenses, such as
depreciation, bad debts or depletion. Interest cannot be
Monthly Income/Expense Statement for deducted as a separate expense if it is already included in any
Business other allowable installment payments.

Identify a time period that reflects your typical business income Attachments Required
and expenses (e.g., 3, 6, 9 or 12 months). Complete the Include attachments if additional space is needed to respond
average monthly income/expense statement for the stated time completely to any question. You may be asked to provide
period. The business information should reconcile with your additional verification after we review the completed Form
business profit and loss statement. 433-B.

Do not complete lines 47, 48 and 49 (For IRS use only). Certification for Signature Line
The partner, corporate officer, or LLC member must sign Form
Total Monthly Business Income 433-B, Collection Information Statement for Businesses, under
penalties of perjury. The signature certifies that the information
Item 25 – Gross Receipts from Sales/Services is accurate and complete. Any changes made after signing the
Enter the amount of money received by the business from all form should be initialed and dated.
sources for the goods sold or services rendered. This figure is
the total before any costs or expenses are subtracted. Distributions from Businesses
Distributions from partnerships and subchapter S corporations
Item 26 – Gross Rental Income reported on Schedule K-1 and from limited liability companies
Enter the amount of gross rents which represent payments reported on Form 1040, Schedule C, D, or E, should be
received for the use of business assets and may be in the form included in the total distributions on Line 25, page 4 of the
of monies, services, assets, bartering or any combination of Form 433-A, Collection Information Statement for Wage
these. Earners and Self-Employed Individuals.

Item 27 - Interest Income
Enter the amount of interest received by the business from
loans, notes, mortgages, bonds, bank deposits, tax refunds,
etc.

Item 28 - Dividends
Enter the amount of dividends received by the business from
U.S. and foreign sources.

Item 29 – Cash Receipts
Include cash received from customers that is not included in
income items 25 through 28.

Publication 5059 (12-2012) Catalog Number 60901W Department of the Treasury Internal Revenue Service www.irs.gov

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