Form 433-B (Rev. 2-2019)

1 form 433-B (Rev. December 2012)Department of the Treasury internal revenue ServiceCollection Information Statement for No. 16649 PForm 433-B (Rev. 12-2012)Note: Complete all entry spaces with the current data available or "N/A" (not applicable). Failure to complete all entry spaces may result in rejection of your request or significant delay in account resolution. Include attachments if additional space is needed to respond completely to any 1: Business Information1aBusiness Name 1bBusiness Street AddressMailing AddressCityState ZIP1d1cBusiness Telephone()1eType of Business1fBusiness Website (web address)County2aEmployer Identification No. (EIN) 2bType of entity (Check appropriate box below)PartnershipCorporationOtherLimited Liability Company (LLC) classified as a corporationOther LLC - Include number of members2cmmddyyyy3aNumber of Employees3b3cFrequency of Tax Deposits 3d Is the business enrolled in Electronic Federal Tax Payment System (EFTPS) YesNoMonthly Gross Payroll 4 Does the business engage in e-Commerce (Internet sales) If yes, complete 5a and PROCESSOR ( , PayPal, , Google Checkout, etc.)

2 Name and Address (Street, City, State, ZIP code)Payment Processor Account Number5a5bCREDIT CARDS ACCEPTED BY THE BUSINESSType of Credit Card ( , Visa, Mastercard, etc.) Merchant Account NumberIssuing Bank Name and Address (Street, City, State, ZIP code)6aPhone6bPhone6cPhoneSection 2: Business Personnel and ContactsPARTNERS, OFFICERS, LLC MEMBERS, MAJOR SHAREHOLDERS, NameTitleHome AddressCityState ZIPR esponsible for Depositing Payroll TaxesYesNoSocial Security NumberHome Telephone ()Work/Cell Phone ()Ownership Percentage & Shares or InterestAnnual Salary/Draw7bFull NameTitleHome AddressCityState ZIPR esponsible for Depositing Payroll TaxesYesNoSocial Security NumberHome Telephone ()Work/Cell Phone ()Ownership Percentage & Shares or InterestAnnual Salary/Draw7cFull NameTitleHome AddressCityState ZIPR esponsible for Depositing Payroll TaxesYesNoSocial Security NumberHome Telephone ()Work/Cell Phone ()

3 Ownership Percentage & Shares or InterestAnnual Salary/Draw7dFull NameTitleHome AddressCityState ZIPR esponsible for Depositing Payroll TaxesYesNoSocial Security NumberHome Telephone ()Work/Cell Phone ()Ownership Percentage & Shares or InterestAnnual Salary/DrawDate Incorporated/Established form 433-B (Rev. 12-2012) Page 2 form 433-B (Rev. 12-2012)Section 3: Other Financial Information (Attach copies of all applicable documents)8 Does the business use a Payroll Service Provider or Reporting Agent (If yes, answer the following) YesNoName and Address (Street, City, State, ZIP code)Effective dates (mmddyyyy)9Is the business a party to a lawsuit (If yes, answer the following)YesNo Plaintiff DefendantLocation of FilingRepresented byDocket/Case of Suit$Possible Completion Date (mmddyyyy)Subject of Suit10 Has the business ever filed bankruptcy (If yes, answer the following)YesNoDate Filed (mmddyyyy)Date Dismissed (mmddyyyy)Petition of Filing11Do any related parties ( , officers, partners, employees) have outstanding amounts owed to the business (If yes, answer the following)

4 YesNoName and Address (Street, City, State, ZIP code) Date of Loanmmddyyyy$ Current Balance As of Payment DatePayment Amount$12 Have any assets been transferred, in the last 10 years, from this business for less than full value (If yes, answer the following) YesNoList AssetValue at Time of Transfer$ Date Transferred (mmddyyyy) To Whom or Where Transferred13 Does this business have other business affiliations ( , subsidiary or parent companies) (If yes, answer the following)YesNo Related Business EIN:Related Business Name and Address (Street, City, State, ZIP code)14 Any increase/decrease in income anticipated (If yes, answer the following)YesNoExplain (Use attachment if needed)How much will it increase/decrease$ When will it increase/decreaseSection 4: Business Asset and Liability Information16aCASH ON HAND Include cash that is not in the bank$BUSINESS BANK ACOUNTS Include online and mobile accounts ( , PayPal), money market accounts, savings accounts, checking accounts and stored value cards ( , payroll cards, government benefit cards, etc.)

5 List safe deposit boxes including location, box number and value of contents. Attach list of of AccountFull Name and Address (Street, City, State, ZIP code) of Bank, Savings & Loan, Credit Union or Financial InstitutionAccount Number Account Balance As ofmmddyyyy17a$ 17b$ 17c$ 17dTotal Cash in Banks (Add lines 17a through 17c and amounts from any attachments)$Total Cash on Hand15Is the business a Federal Government Contractor (Include Federal Government contracts in #18, Accounts/Notes Receivable)YesNo16bIs there a safe on the business premises YesNoContentsDate Discharged (mmddyyyy) form 433-B (Rev. 12-2012) Page 3 form 433-B (Rev. 12-2012)Name & Address (Street, City, State, ZIP code)Status ( , age, factored, other)Date Due (mmddyyy)Invoice Number or Government Grant or Contract NumberAmount Due18aContact NamePhone$ 18bContact NamePhone$ 18cContact NamePhone$ 18dContact NamePhone$ 18eContact NamePhone$ 18fOutstanding Balance (Add lines 18a through 18e and amounts from any attachments)$INVESTMENTS List all investment assets below.

6 Include stocks, bonds, mutual funds, stock options, certificates of deposit and commodities ( , gold, silver, copper, etc.).Name of Company & Address (Street, City, State, ZIP code)Used as collateral on loanCurrent ValueLoan BalanceEquity Value Minus Loan19aPhoneYesNo$ $ $ 19bPhoneYesNo$ $ $ 19cTotal Investments (Add lines 19a, 19b, and amounts from any attachments)$Full Name & Address (Street, City, State, ZIP code)Credit LimitAmount Owed As ofmmddyyyyAvailable Credit As ofmmddyyyy20aAccount No.$ $ $ 20bAccount No.$ $ $ 20cTotal Credit Available (Add lines 20a, 20b, and amounts from any attachments)$ACCOUNTS/NOTES RECEIVABLE Include e-payment accounts receivable and factoring companies, and any bartering or online auction accounts. (List all contracts separately including contracts awarded, but not started).

7 Include Federal, state and local government grants and CREDIT Include all lines of credit and credit cards. form 433-B (Rev. 12-2012) Page 4 REAL PROPERTY Include all real property and land contracts the business owns/ Date (mmddyyyy)Current Fair Market Value (FMV) Current Loan BalanceAmount of Monthly PaymentDate of Final Payment (mmddyyyy)Equity FMV Minus Loan21aProperty Description$$$$Location (Street, City, State, ZIP code) and CountyLender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and PhonePhone 21bProperty Description$$$$Location (Street, City, State, ZIP code) and CountyLender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and PhonePhone 21cProperty Description$$$$Location (Street, City, State, ZIP code)

8 And CountyLender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and PhonePhone 21dProperty Description$$$$Location (Street, City, State, ZIP code) and CountyLender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and PhonePhone21eTotal Equity (Add lines 21a through 21d and amounts from any attachments)$VEHICLES, LEASED AND PURCHASED Include boats, RVs, motorcycles, all-terrain and off-road vehicles, trailers, mobile homes, NumberVehicle Identification Number (VIN)Purchase/Lease Date (mmddyyyy)Current Fair Market Value (FMV) $Current Loan Balance$Amount of Monthly Payment$Date of Final Payment (mmddyyyy)Equity FMV Minus Loan$Lender/Lessor Name, Address, (Street, City, State, ZIP code) and PhonePhone22bYearMileageMake/ModelLicens e/Tag NumberVehicle Identification Number (VIN)$$$$Lender/Lessor Name, Address, (Street, City, State, ZIP code) and PhonePhone22cYearMileageMake/ModelLicens e/Tag NumberVehicle Identification Number (VIN)$$$$Lender/Lessor Name, Address, (Street, City, State, ZIP code) and PhonePhone22dYearMileageMake/ModelLicens e/Tag NumberVehicle Identification Number (VIN)$$$$Lender/Lessor Name, Address, (Street, City, State, ZIP code) and PhonePhone22eTotal Equity (Add lines 22a through 22d and amounts from any attachments)$ form 433-B (Rev.)

9 12-2012) form 433-B (Rev. 12-2012) Page 5 BUSINESS EQUIPMENT AND INTANGIBLE ASSETS Include all machinery, equipment, merchandise inventory, and other assets in 23a through 23d. List intangible assets in 23e through 23g (licenses, patents, logos, domain names, trademarks, copyrights, software, mining claims, goodwill and trade secrets.)Purchase/Lease Date (mmddyyyy)Current Fair Market Value (FMV) Current Loan BalanceAmount of Monthly PaymentDate of Final Payment (mmddyyyy)Equity FMV Minus Loan23aAsset Description$$$$Location of asset (Street, City, State, ZIP code) and CountyLender/Lessor Name, Address, (Street, City, State, ZIP code) and PhonePhone 23bAsset Description$$$$Location of asset (Street, City, State, ZIP code) and CountyLender/Lessor Name, Address, (Street, City, State, ZIP code) and PhonePhone 23cAsset Description$$$$Location of asset (Street, City, State, ZIP code) and CountyLender/Lessor Name, Address, (Street, City, State, ZIP code)

10 And PhonePhone 23dAsset Description$$$$Location of asset (Street, City, State, ZIP code) and CountyLender/Lessor Name, Address, (Street, City, State, ZIP code) and PhonePhone23eIntangible Asset Description$23fIntangible Asset Description$23gIntangible Asset Description$23hTotal Equity (Add lines 23a through 23g and amounts from any attachments)$BUSINESS LIABILITIES Include notes and judgements not listed previously on this Liabilities24aDescription:Secured/ UnsecuredSecuredUnsecured Date Pledged (mmddyyyy) Balance Owed$ Date of Final Payment (mmddyyyy)Payment Amount$ NameStreet AddressCity/State/ZIP codePhone24bDescription:SecuredUnsecured $ $ NameStreet AddressCity/State/ZIP codePhone24cTotal Payments (Add lines 24a and 24b and amounts from any attachments)$ form 433-B (Rev.)