Form 656 Booklet - Offer In Compromise Page 15
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28Department of the Treasury — Internal Revenue Service
433-B (OIC)
Form
Collection Information Statement for Businesses
(March 2011)
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
Business address
County of Business Location
(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
Does the business use a payroll service provider?
Yes
No
Federal Contractor
Total Number of Employees
If yes, list provider name and address
(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
Social Security Number
Percent of Ownership
Home address
(Street, City, State, ZIP Code)
Primary Phone
Secondary Phone
(
)
(
)
-
-
Last Name
First Name
Title
Social Security Number
Percent of Ownership
Home address
(Street, City, State, ZIP Code)
Primary Phone
Secondary Phone
(
)
(
)
-
-
Last Name
First Name
Title
Social Security Number
Percent of Ownership
Home address
(Street, City, State, ZIP Code)
Primary Phone
Secondary Phone
(
)
(
)
-
-
433-B (OIC)
Catalog Number 55897B
Form
(3-2011)
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