Form 433-B
(Rev. December 2012)                   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   Business Website (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.) 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, ETC.
7a   Full Name                                                                           Social Security 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                                                                           Social Security 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                                                                           Social Security 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                                                                           Social Security 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
www.irs.gov                                                 Cat. No. 16649P                                                       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     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

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.
                                                                                                                                               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)                                              $
                                                                                                                               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.
                                                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 and commodities  
   (e.g., gold, silver, copper, etc.).
   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)                                        $
                                                                                                                         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/      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)                                         $
                                                                                                                      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/        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)                                     $
                                                                                                                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 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 books, portion of employment taxes.
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)