Form 656-B - Offer In Compromise Booklet Page 20
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32Page 4 of 6
Section 2
Business Asset Information
(Continued)
Other Business Equipment
[If you have more than one piece of equipment, please list on a separate attachment and put the total of all equipment in box (5b)]
Type of equipment
Current Market Value
Minus Loan Balance
Total value of equipment
(if leased or used in the production of
$
X .8 = $
– $
(5a) $
=
income enter 0 as the total value)
Total value of equipment listed from attachment [current market value X .8 minus any loan balance(s)]
(5b) $
Total value of all business equipment
Add lines (5a) and (5b) =
(5) $
Box A
Do not include amount on the lines with a letter beside the number. Round to the nearest dollar.
Available Equity in Assets
Do not enter a negative number. If any line item is a negative number, enter "0" on that line.
Add lines (1) through (5) and enter the amount in Box A =
$
Section 3
Business Income Information
Enter the average gross monthly income of your business. To determine your gross monthly income use the most recent 6-12 months documentation of
commissions, invoices, gross receipts from sales/services, etc.; most recent 6-12 months earnings statements, etc., from every other source of income (such as
rental income, interest and dividends, or subsidies); or you may use the most recent 6-12 months Profit and Loss (P&L) to provide the information of income and
expenses.
Note: If you provide a current profit and loss statement for the information below, enter the total gross monthly income in Box B below. Do not
complete lines (6) - (10). Entire household income should also include income that is considered as not taxable and may not be included on your tax
return.
Gross receipts
(6) $
Gross rental income
(7) $
Interest income
(8) $
Dividends
(9) $
Other income (Specify on attachment)
(10) $
Box B
Round to the nearest dollar.
Total Business Income
Do not enter a negative number. If any line item is a negative number, enter "0" on that line.
Add lines (6) through (10) and enter the amount in Box B =
$
Section 4
Business Expense Information
Enter the average gross monthly expenses for your business using your most recent 6-12 months statements, bills, receipts, or other documents
showing monthly recurring expenses.
Note: If you provide a current profit and loss statement for the information below, enter the total monthly expenses in Box C below. Do not
complete lines (11) - (20).
Materials purchased (e.g., items directly related to the production of a product or service)
(11) $
Inventory purchased (e.g., goods bought for resale)
(12) $
Gross wages and salaries
(13) $
Rent
(14) $
Supplies (items used to conduct business and used up within one year, e.g., books, office supplies, professional
equipment, etc.)
(15) $
Utilities/telephones
(16) $
Vehicle costs (gas, oil, repairs, maintenance)
(17) $
Insurance (other than life)
(18) $
Current taxes (e.g., real estate, state, and local income tax, excise franchise, occupational, personal property,
sales and employer's portion of employment taxes, etc.)
(19) $
Other expenses (e.g., secured debt payments. Specify on attachment. Do not include credit card payments)
(20) $
Box C
Round to the nearest dollar.
Total Business Expenses
Do not enter a negative number. If any line item is a negative number, enter "0" on that line.
Add lines (11) through (20) and enter the amount in Box C =
$
Box D
Round to the nearest dollar.
Remaining Monthly Income
Do not enter a negative number. If any line item is a negative number, enter "0" on that line.
$
Subtract Box C from Box B and enter the amount in Box D =
433-B (OIC)
Form
(Rev. 3-2017)
Catalog Number 55897B
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