Form 656 - Offer In Compromise (Including Form 433-A (Oic), Form 433-B (Oic)) Page 18
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28Page 4 of 6
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 a 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 2 below. Do
not complete lines (6) - (10).
Gross receipts
(6)
$
Gross rental income
(7)
$
Interest income
(8)
$
Dividends
(9)
$
Other income (Specify on attachment)
(10) $
Box 2 Total Business Income
Add lines (6) through (10) and enter the amount in Box 2 =
$
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 3 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
(15) $
equipment, etc.)
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 3 Total Business Expenses
Add lines (11) through (20) and enter the amount in Box 3 =
$
Box 4 Remaining Monthly Income
Subtract Box 3 from Box 2 and enter the amount in Box 4 =
If number is less than zero, enter zero.
$
433-B (OIC)
Catalog Number 55897B
Form
(Rev. 5-2012)
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