Form Md 433-B - Collection Information Statement For Businesses
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4MD 433-B
Form
(Rev. July 2000)
Collection Information Statement for Businesses
State of Maryland
Comptroller of Maryland
(If you need additional space, please attach a separate sheet.)
Note: Complete all blocks, except shaded areas. Write "N/A" (not applicable) in those blocks that do not apply.
1 Name and address of business
2 Business phone number (
) ___________________________
3 (Check appropriate box)
Sole Proprietor
Other (specify)
Partnership
_______________________
County _________________
Corporation
_______________________
4 Name and title of person being interviewed
5 Employer identification number
6 Type of business
7 Information about owner, partners, officers, major shareholder, etc.
Effective
Phone
Social Security
Total Shares
Name and Title
Date
Home Address
Number
Number
of Interest
Section I
General Financial Information
8 Latest filed income tax return
Form
Tax Year Ended
Net income before taxes
9 Bank accounts (List all types of accounts including payroll and general savings, certificates of deposit, etc.)
Name of Institution
Address
Type of Account
Account No.
Balance
Total (Enter in Item 17) ......................................
10 Bank credit available (lines of credit, etc.)
Credit
Amount
Credit
Monthly
Name of Institution
Address
Limit
Owed
Available
Payments
Totals (Enter in Items 24 or 25 as appropriate) .....................................................
11 Location, box number, and contents of all safe deposit boxes rented or accessed
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Parent category: Legal