Form 656 - Offer In Compromise (Including Form 433-A (Oic), Form 433-B (Oic)) Page 15
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28Department of the Treasury — Internal Revenue Service
433-B (OIC)
Form
Collection Information Statement for Businesses
(Rev. May 2012)
Complete this form if your business is a
Corporation
If your business is a sole proprietorship (filing Schedule C), do not use
this form. Instead, complete Form 433-A (OIC) Collection Information
Partnership
Statement for Wage Earners and Self-Employed Individuals.
Limited Liability Company (LLC) classified as a corporation
Other multi-owner/multi-member LLC
Single member LLC
Include attachments if additional space is needed to respond completely to any question.
Section 1
Business Information
Business Name
Employer Identification Number
County of Business Location
Business address
(street, city, state, zip code)
Description of Business and dba or "Trade Name"
Primary Phone
Secondary Phone
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?
(
)
-
Yes
No If yes, list provider name and address in box below
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
Social Security Number
Percent of Ownership and annual salary
Home address
(Street, City, State, ZIP Code)
Primary Phone
Secondary Phone
(
)
(
)
-
-
Title
Last Name
First Name
Social Security Number
Percent of Ownership and annual salary
Home address
(Street, City, State, ZIP Code)
Primary Phone
Secondary Phone
(
)
(
)
-
-
433-B (OIC)
Catalog Number 55897B
Form
(Rev. 5-2012)
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