Form 433-B (Oic) - Collection Information Statement For Businesses Page 6

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Page 6 of 6
Section 7
Signatures
Under penalties of perjury, I declare that I have examined this offer, including accompanying documents, and to the best of my knowledge
it is true, correct, and complete.
Signature of Taxpayer
Title
Date
(mm/dd/yyyy)
Remember to include all applicable attachments from list below.
A current Profit and Loss statement covering at least the most recent 6-12 month period, if appropriate.
Copies of the three most recent statements for each bank, investment, and retirement account.
If an asset is used as collateral on a loan, include copies of the most recent statement from lender(s) on loans, monthly
payments, loan payoffs, and balances.
Copies of the most recent statement of outstanding notes receivable.
Copies of the most recent statements from lenders on loans, mortgages (including second mortgages), monthly payments,
loan payoffs, and balances.
Copies of relevant supporting documentation of the special circumstances described in the "Explanation of Circumstances"
on Form 656, if applicable.
Attach a Form 2848, Power of Attorney, if you would like your attorney, CPA, or enrolled agent to represent you and you
do not have a current form on file with the IRS.
433-B (OIC)
Catalog Number 55897B
Form
(Rev. 1-2014)

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