Form 433-B
(February 2019)                               Collection Information Statement for Businesses
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) 
                                                                      2b           Type of entity (Check appropriate box below)
1b   Business Street Address                                                          Partnership        Corporation      Other
                                                                                      Limited Liability Company (LLC) classified as a corporation
     Mailing Address                                                                  Other LLC - Include number of members
     City                               State             ZIP         2c           Date Incorporated/Established 
1c   County                                                                                                          mmddyyyy
1d   Business Telephone    (            )                             3a           Number of Employees
1e   Type of Business                                                 3b           Monthly Gross Payroll 
                                                                      3c           Frequency of Tax Deposits 
1f   BusinessWebsite       (web address)                              3d           Is the business enrolled in Electronic 
                                                                                   Federal Tax Payment System (EFTPS)          Yes               No
4    Does the business engage in e-Commerce (Internet sales) If yes, complete 5a and 5b.                                       Yes               No
PAYMENT PROCESSOR (e.g., PayPal, Authorize.net, Google Checkout, etc.) Include virtual currency wallet, exchange or digital currency exchange.
                                 Name and Address (Street, City, State, ZIP code)                                Payment Processor Account Number

5a

5b
CREDIT CARDS ACCEPTED BY THE BUSINESS
      Type of Credit Card        Merchant Account Number              Issuing Bank Name and Address (Street, City, State, ZIP code)
  (e.g., Visa, Mastercard, etc.) 

6a                                                            Phone

6b                                                            Phone

6c                                                            Phone
Section 2: Business Personnel and Contacts
PARTNERS, OFFICERS, LLC MEMBERS, MAJOR SHAREHOLDERS (Foreign and Domestic), ETC.
7a   Full Name                                                                            Taxpayer Identification Number
     Title                                                                                Home Telephone       (          )
     Home Address                                                                         Work/Cell Phone      (          )
     City                               State                  ZIP                        Ownership Percentage & Shares or Interest
     Responsible for Depositing Payroll Taxes           Yes   No                          Annual Salary/Draw
7b   Full Name                                                                            Taxpayer Identification Number
     Title                                                                                Home Telephone       (          )
     Home Address                                                                         Work/Cell Phone      (          )
     City                               State                  ZIP                        Ownership Percentage & Shares or Interest
     Responsible for Depositing Payroll Taxes           Yes   No                          Annual Salary/Draw
7c   Full Name                                                                            Taxpayer Identification Number
     Title                                                                                Home Telephone       (          )
     Home Address                                                                         Work/Cell Phone      (          )
     City                               State                  ZIP                        Ownership Percentage & Shares or Interest
     Responsible for Depositing Payroll Taxes           Yes   No                          Annual Salary/Draw
7d   Full Name                                                                            Taxpayer Identification Number
     Title                                                                                Home Telephone       (          )
     Home Address                                                                         Work/Cell Phone      (          )
     City                               State                  ZIP                        Ownership Percentage & Shares or Interest
     Responsible for Depositing Payroll Taxes           Yes   No                          Annual Salary/Draw

Catalog Number 16649P                                         www.irs.gov                                                 Form 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)                                                                                                                           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     No
    Name and Address (Street, City, State, ZIP code)                                                                           Effective dates (mmddyyyy)

9   Is the business a party to a lawsuit (If yes, answer the following)                                                                            Yes     No
                                   Location of Filing                           Represented by                                 Docket/Case No.
      Plaintiff           Defendant
    Amount of Suit                 Possible Completion Date (mmddyyyy)          Subject of Suit
    $
10  Has the business ever filed bankruptcy (If yes, answer the following)                                                                          Yes     No
    Date Filed (mmddyyyy)   Date Dismissed (mmddyyyy)             Date Discharged (mmddyyyy)           Petition No.            District of Filing

11  Do any related parties (e.g., officers, partners, employees) have outstanding amounts owed to the business (If yes, answer the following)      Yes     No
    Name and Address (Street, City, State, ZIP code)               Date of Loan  Current Balance As of               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)             Yes     No
    List Asset                                                    Value at Time of Transfer    Date Transferred (mmddyyyy)      To Whom or Where Transferred
                                                                  $
13  Does this business have other business affiliations (e.g., subsidiary or parent companies) (If yes, answer the following)                      Yes     No
    Related Business Name and Address (Street, City, State, ZIP code)                                                           Related Business EIN:

14  Any increase/decrease in income anticipated (If yes, answer the following)                                                                     Yes     No
    Explain (Use attachment if needed)                                                  How much will it increase/decrease      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 (Foreign and Domestic)

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 mobileaccounts            (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.
                                                                                                                                               Account Balance 
     Type of                       Full Name and Address (Street, City, State, ZIP code) of                     Account Number                As of
     Account                       Bank, Savings & Loan, Credit Union or Financial Institution
                                                                                                                                                   mmddyyyy

17a                                                                                                                               $ 

17b                                                                                                                               $ 

17c                                                                                                                               $ 

17d Total Cash in Banks (Add lines 17a through 17c and amounts from any attachments)                                              $

Catalog Number 16649P                                             www.irs.gov                                              Form 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)                                                                                                                       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.

                                                Status (e.g., age,             Date Due  Invoice Number or Government        Amount Due
                                                factored, other)
Name & Address (Street, City, State, ZIP code)                                 (mmddyyy)  Grant or Contract Number
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, commodities (e.g., 
   gold, silver, copper, etc.) and virtual currency (e.g., Bitcoin, Ripple and Litecoin).
   Name of Company & Address                    Used as collateral                                                                             Equity  
   (Street, City, State, ZIP code)                      on loan                     Current Value        Loan Balance
                                                                                                                             Value Minus Loan
19a
                                                        Yes                    No
   Phone                                                                         $                     $                 $ 
19b
                                                        Yes                    No
   Phone                                                                         $                     $                 $ 

19c Total Investments (Add lines 19a, 19b, and amounts from any attachments)                                             $
   AVAILABLE CREDIT  Include all lines of credit and credit cards. 
                                                                                                         Amount Owed         Available Credit 
   Full Name & Address (Street, City, State, ZIP code)                                   Credit Limit    As of               As of
                                                                                                                mmddyyyy                       mmddyyyy
20a

   Account No.                                                                   $                     $                 $ 
20b

   Account No.                                                                   $                     $                 $ 

20c Total Credit Available (Add lines 20a, 20b, and amounts from any attachments)                                        $

Catalog Number 16649P                                   www.irs.gov                                                     Form 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)                                                                                                          Page  4
REAL PROPERTY  Include all real property and land contracts the business owns/leases/rents.
                                            Purchase/      Current Fair   Current Loan       Amount of    Date of Final           Equity  
                                            Lease Date   Market Value         Balance        Monthly      Payment        FMV Minus Loan
                                            (mmddyyyy)     (FMV)                             Payment      (mmddyyyy)
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/      Current Fair   Current Loan       Amount of    Date of Final           Equity  
                                            Lease Date   Market Value         Balance        Monthly      Payment        FMV Minus Loan
                                            (mmddyyyy)     (FMV)                             Payment      (mmddyyyy)
22a Year                 Make/Model
                                                         $                $                $                             $
    Mileage              License/Tag Number Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone

    Vehicle Identification Number (VIN)
                                                                                           Phone
22b Year                 Make/Model
                                                         $                $                $                             $
    Mileage              License/Tag Number Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone

    Vehicle Identification Number (VIN)
                                                                                           Phone
22c Year                 Make/Model
                                                         $                $                $                             $
    Mileage              License/Tag Number Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone

    Vehicle Identification Number (VIN)
                                                                                           Phone
22d Year                 Make/Model
                                                         $                $                $                             $
    Mileage              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)                                      $

Catalog Number 16649P                                      www.irs.gov                                             Form 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)                                                                                                      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/         Current Fair    Current Loan        Amount of  Date of Final          Equity  
                                      Lease Date      Market Value            Balance       Monthly    Payment        FMV Minus Loan
                                      (mmddyyyy)                 (FMV)                      Payment    (mmddyyyy)
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.
                                                                                                       Date of Final 
    Business Liabilities                              Secured/          Date Pledged    Balance Owed   Payment                Payment  
                                                      Unsecured        (mmddyyyy)                      (mmddyyyy)             Amount
24a Description:
                                                      Secured

                                                      Unsecured                       $                               $ 
    Name
    Street Address
    City/State/ZIP code                                                                     Phone
24b Description:
                                                      Secured

                                                      Unsecured                       $                               $ 
    Name
    Street Address
    City/State/ZIP code                                                                     Phone

24c Total Payments (Add lines 24a and 24b and amounts from any attachments)                             $

Catalog Number 16649P                                   www.irs.gov                                     Form 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)                                                                                                     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 Income                                          Total Monthly Business Expenses
                 Income Source                       Gross Monthly                     Expense items                     Actual Monthly
25   Gross Receipts from Sales/Services           $                   36   Materials Purchased 1                       $ 
26   Gross Rental Income                          $                   37   Inventory Purchased 2                       $
27   Interest Income                              $                   38   Gross Wages & Salaries                      $
28   Dividends                                    $                   39   Rent                                        $
29   Cash Receipts (Not included in lines 25-28)  $                   40   Supplies 3                                  $ 
       Other Income (Specify below)                                   41   Utilities/Telephone 4                       $
30                                                $                   42   Vehicle Gasoline/Oil                        $
31                                                $                   43   Repairs & Maintenance                       $
32                                                $                   44   Insurance                                   $ 
33                                                $                   45   Current Taxes 5                             $
34                                                $                   46   Other Expenses (Specify)                    $
35   Total Income (Add lines 25 through 34)       $                   47   IRS Use Only-Allowable Installment Payments $
                                                                      48   Total Expenses (Add lines 36 through 47)    $
                                                                      49   Net Income (Line 35 minus Line 48)          $
1   Materials Purchased: Materials are items directly related to the  4   Utilities/Telephone: Utilities include gas, electricity, water, oil, other 
 production of a product or service.                                        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, 
3   Supplies: Supplies are items used to conduct business and are           franchise, occupational, personal property, sales and the employer's 
 consumed or used up within one year. This could be the cost of             portion of employment taxes.
 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)

Privacy Act: The information requested on this Form is covered under Privacy Acts and Paperwork Reduction Notices which have already been 
provided to the taxpayer.

Catalog Number 16649P                                         www.irs.gov                                      Form 433-B (Rev. 2-2019)