IRS Form 433-B "Collection Information Statement for Businesses"

What Is IRS Form 433-B?

This is a tax form that was released by the Internal Revenue Service (IRS) - a subdivision of the U.S. Department of the Treasury on February 1, 2019. As of today, no separate filing guidelines for the form are provided by the IRS.

Form Details:

  • A 6-page form available for download in PDF;
  • Actual and valid for filing 2022 taxes;
  • Editable, printable, and free;
  • Fill out the form in our online filing application.

Download a fillable version of IRS Form 433-B through the link below or browse more documents in our library of IRS Forms.

ADVERTISEMENT
ADVERTISEMENT

Download IRS Form 433-B "Collection Information Statement for Businesses"

Download PDF

Fill PDF online

Rate (4.6 / 5) 70 votes
Page background image
433-B
Form
Collection Information Statement for Businesses
(February 2019)
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
County
mmddyyyy
1c
(
)
1d
3a Number of Employees
Business Telephone
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
Yes
No
Does the business engage in e-Commerce (Internet sales) If yes, complete 5a and 5b.
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.
Taxpayer Identification Number
7a Full Name
(
)
Title
Home Telephone
(
)
Home Address
Work/Cell Phone
Ownership Percentage & Shares or Interest
City
State
ZIP
Responsible for Depositing Payroll Taxes
Yes
No
Annual Salary/Draw
Taxpayer Identification Number
7b Full Name
(
)
Title
Home Telephone
(
)
Home Address
Work/Cell Phone
Ownership Percentage & Shares or Interest
City
State
ZIP
Responsible for Depositing Payroll Taxes
Yes
No
Annual Salary/Draw
Taxpayer Identification Number
7c Full Name
(
)
Title
Home Telephone
(
)
Home Address
Work/Cell Phone
City
State
ZIP
Ownership Percentage & Shares or Interest
Yes
No
Responsible for Depositing Payroll Taxes
Annual Salary/Draw
Taxpayer Identification Number
7d Full Name
(
)
Title
Home Telephone
(
)
Home Address
Work/Cell Phone
Ownership Percentage & Shares or Interest
City
State
ZIP
Annual Salary/Draw
Yes
No
Responsible for Depositing Payroll Taxes
433-B
Catalog Number 16649P
www.irs.gov
Form
(Rev. 2-2019)
433-B
Form
Collection Information Statement for Businesses
(February 2019)
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
County
mmddyyyy
1c
(
)
1d
3a Number of Employees
Business Telephone
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
Yes
No
Does the business engage in e-Commerce (Internet sales) If yes, complete 5a and 5b.
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.
Taxpayer Identification Number
7a Full Name
(
)
Title
Home Telephone
(
)
Home Address
Work/Cell Phone
Ownership Percentage & Shares or Interest
City
State
ZIP
Responsible for Depositing Payroll Taxes
Yes
No
Annual Salary/Draw
Taxpayer Identification Number
7b Full Name
(
)
Title
Home Telephone
(
)
Home Address
Work/Cell Phone
Ownership Percentage & Shares or Interest
City
State
ZIP
Responsible for Depositing Payroll Taxes
Yes
No
Annual Salary/Draw
Taxpayer Identification Number
7c Full Name
(
)
Title
Home Telephone
(
)
Home Address
Work/Cell Phone
City
State
ZIP
Ownership Percentage & Shares or Interest
Yes
No
Responsible for Depositing Payroll Taxes
Annual Salary/Draw
Taxpayer Identification Number
7d Full Name
(
)
Title
Home Telephone
(
)
Home Address
Work/Cell Phone
Ownership Percentage & Shares or Interest
City
State
ZIP
Annual Salary/Draw
Yes
No
Responsible for Depositing Payroll Taxes
433-B
Catalog Number 16649P
www.irs.gov
Form
(Rev. 2-2019)
2
Form 433-B (Rev. 2-2019)
Page
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
Yes
No
Do any related parties (e.g., officers, partners, employees) have outstanding amounts owed to the business (If yes, answer the following)
Name and Address (Street, City, State, ZIP code)
Current Balance As of
Payment Date Payment Amount
Date of Loan
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
Date Transferred (mmddyyyy)
To Whom or Where Transferred
Value at Time of Transfer
$
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
How much will it increase/decrease
Explain (Use attachment if needed)
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 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)
433-B
Catalog Number 16649P
www.irs.gov
Form
(Rev. 2-2019)
3
Form 433-B (Rev. 2-2019)
Page
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
Name & Address (Street, City, State, ZIP code)
Amount Due
factored, other)
(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).
Equity
Name of Company & Address
Used as collateral
Current Value
Loan Balance
(Street, City, State, ZIP code)
on loan
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)
$
433-B
Catalog Number 16649P
www.irs.gov
Form
(Rev. 2-2019)
4
Form 433-B (Rev. 2-2019)
Page
REAL PROPERTY Include all real property and land contracts the business owns/leases/rents.
Purchase/
Current Fair
Amount of
Date of Final
Current Loan
Equity
Lease Date
Market Value
Monthly
Payment
Balance
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
Amount of
Date of Final
Current Loan
Equity
Lease Date
Market Value
Monthly
Payment
Balance
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)
$
433-B
Catalog Number 16649P
www.irs.gov
Form
(Rev. 2-2019)
5
Form 433-B (Rev. 2-2019)
Page
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
Amount of
Date of Final
Current Loan
Equity
Lease Date
Market Value
Monthly
Payment
Balance
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
$
Intangible Asset Description
23f
$
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
Secured/
Date Pledged
Payment
Business Liabilities
Balance Owed
Payment
Unsecured
(mmddyyyy)
Amount
(mmddyyyy)
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)
$
433-B
Catalog Number 16649P
www.irs.gov
Form
(Rev. 2-2019)
Page of 6