Form 656-B - Offer In Compromise Booklet Page 17
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32Department of the Treasury — Internal Revenue Service
433-B (OIC)
Form
Collection Information Statement for Businesses
(Rev. March 2017)
Complete this form if your business is a
► Corporation
► Limited Liability Company (LLC) classified as a corporation
► Partnership
► Other multi-owner/multi-member LLC
Note: If your business is a sole proprietorship or a disregarded single member LLC taxed as a sole proprietor (filing Schedule C, D, E, F, etc.),
do not use this form. Instead, complete Form 433-A (OIC) Collection Information Statement for Wage Earners and Self-Employed Individuals.
This form should only be used with the Form 656, Offer in Compromise.
Include attachments if additional space is needed to respond completely to any question.
Section 1
Business Information
Business Name
Employer Identification Number
Business Physical Address
County of Business Location
(street, city, state, zip code)
Description of Business and DBA or "Trade Name"
Primary Phone
Secondary Phone
Business Mailing Address
(if different from above or Post Office Box number)
(
)
-
(
)
-
Business website address
Fax Number
Does the business outsource its payroll processing and tax return
preparation for a fee?
(
)
-
If yes, list provider name and address in box below
Yes
No
Federal Contractor
Total Number of Employees
(Street, City, State, ZIP Code)
Yes
No
Frequency of Tax Deposits
Average Gross Monthly Payroll
$
Provide information about all partners, officers, LLC members, major shareholders (foreign and domestic), etc., associated with the business.
Include attachments if additional space is needed.
Last Name
First Name
Title
Percent of Ownership and Annual Salary
Social Security Number
Home Address
(Street, City, State, ZIP Code)
-
-
Primary Phone
Secondary Phone
(
)
-
(
)
-
Last Name
First Name
Title
Percent of Ownership and Annual Salary
Social Security Number
Home Address
(Street, City, State, ZIP Code)
-
-
Primary Phone
Secondary Phone
(
)
-
(
)
-
Last Name
First Name
Title
Percent of Ownership and Annual Salary
Social Security Number
Home Address
(Street, City, State, ZIP Code)
-
-
Primary Phone
Secondary Phone
(
)
-
(
)
-
433-B (OIC)
Form
(Rev. 3-2017)
Catalog Number 55897B
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