Form 433b - Collection Information Statement For Businesses
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West Virginia State Tax Department
Form 433B
Collection Information Statement For Businesses
(April 05)
(If you need additional space, please attach a separate sheet)
Complete all blocks, except shaded areas. Write “NA” (non-applicable in those blocks that do not apply.
1.
2
.
(
)
Name and address of business
Business phone number
3 .
(Check appropriate box)
Sole Proprietor
Other (specify)
________
Partnership
______________
County
Corporation
______________
Name and title of person completing form.
4.
5
.
6
.
Name and title of person being interviewed
Employer ID. No.
Type of Business
7. Information about owner, partners, officers, major shareholder, etc.
Name and Title
Effective
H
ome Address
P
hone No.
S
ocial
T
otal Shares or
I
nterest
Date
S
ecurity No.
SECTION I.
GENERAL FINANCIAL INFORMATION
8. Latest filed income tax return
F
orm
T
ax Year
N
et income
E
nded
b
efore taxes
9. Bank accounts (List all types of accounts including payroll and general, savings, certificates of deposits, etc.)
Name of Institution
Address
T
ype of Acct.
A
cct. #
B
alance
T
otal
$
0.00
(Enter in Item 17)
10. Bank credit available
(Lines of credit, etc.)
Name of Institution
Address
Credit
A
mt.
Credit
M
onthly
Limit
O
wed
Available
P
ayments
0.00
0.00
0.00
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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