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Form433-BCollection Information Statement for Businesses(February 2019)Department of the TreasuryInternal Revenue ServiceNote: Complete all entry spaces with the current data available or "N/A" (not applicable). Failure to complete all entry spaces may result in rejection ofyour request or significant delay in account resolution. Include attachments if additional space is needed to respond completely to any question.Section 1: Business Information1a Business Name2a Employer Identification No. (EIN)2b Type of entity (Check appropriate box below)PartnershipCorporationOtherLimited Liability Company (LLC) classified as a corporationOther LLC - Include number of members2c Date Incorporated/Establishedmmddyyyy1b Business Street AddressMailing AddressCity1c County1d Business Telephone1e Type of BusinessState(ZIP)3a3b3c3dNumber of EmployeesMonthly Gross PayrollFrequency of Tax Deposits1f Business Website (web address)Is the business enrolled in ElectronicFederal Tax Payment System (EFTPS)4Does the business engage in e-Commerce (Internet sales) If yes, complete 5a and 5b.YesYesNoNoPAYMENT PROCESSOR (e.g., PayPal, Authorize.net, Google Checkout, etc.) Include virtual currency wallet, exchange or digital currency exchange.Name and Address (Street, City, State, ZIP code)Payment Processor Account Number5a5bCREDIT CARDS ACCEPTED BY THE BUSINESSType of Credit CardMerchant Account Number(e.g., Visa, Mastercard, etc.)Issuing Bank Name and Address (Street, City, State, ZIP code)6aPhone6bPhone6cPhoneSection 2: Business Personnel and ContactsPARTNERS, OFFICERS, LLC MEMBERS, MAJOR SHAREHOLDERS (Foreign and Domestic), ETC.Taxpayer Identification Number7a Full Name)TitleHome Telephone ()Home AddressWork/Cell Phone (OwnershipPercentage&Sharesor InterestCityStateZIPResponsible for Depositing Payroll TaxesYesNoAnnual Salary/DrawTaxpayer Identification Number7b Full Name)TitleHome Telephone ()Home AddressWork/Cell Phone (Ownership Percentage & Shares or InterestCityStateZIPResponsible for Depositing Payroll TaxesYesNoAnnual Salary/DrawTaxpayer Identification Number7c Full Name)TitleHome Telephone ()Home AddressWork/Cell Phone (CityStateResponsible for Depositing Payroll TaxesYesZIPNo7d Full NameTitleHome AddressCityStateResponsible for Depositing Payroll TaxesYesZIPNoCatalog Number 16649Pwww.irs.govOwnership Percentage & Shares or InterestAnnual Salary/DrawTaxpayer Identification Number)Home Telephone ()Work/Cell Phone (Ownership Percentage & Shares or InterestAnnual Salary/DrawForm 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)Page2Section 3: Other Financial Information (Attach copies of all applicable documents)8Does the business use a Payroll Service Provider or Reporting Agent (If yes, answer the following)YesName and Address (Street, City, State, ZIP code)9Effective dates (mmddyyyy)Is the business a party to a lawsuit (If yes, answer the following)PlaintiffAmount of Suit 10YesLocation of FilingRepresented byPossible Completion Date (mmddyyyy)Subject of SuitDate Filed (mmddyyyy)Docket/Case No.Date Dismissed (mmddyyyy)YesDate Discharged (mmddyyyy)Petition No.Date of Loan Current Balance As ofName and Address (Street, City, State, ZIP code)mmddyyyyYes Have any assets been transferred, in the last 10 years, from this business for less than full value (If yes, answer the following)13Value at Time of Transfer Date Transferred (mmddyyyy)YesRelated Business Name and Address (Street, City, State, ZIP code)YesNoRelated Business EIN:Any increase/decrease in income anticipated (If yes, answer the following)YesHow much will it increase/decreaseExplain (Use attachment if needed)NoTo Whom or Where TransferredDoes this business have other business affiliations (e.g., subsidiary or parent companies) (If yes, answer the following)14NoPayment Date Payment Amount List AssetNoDistrict of FilingDo any related parties (e.g., officers, partners, employees) have outstanding amounts owed to the business (If yes, answer the following)12NoDefendantHas the business ever filed bankruptcy (If yes, answer the following)11NoNoWhen will it increase/decrease 15Is the business a Federal Government Contractor (Include Federal Government contracts in #18, Accounts/Notes Receivable)YesNoSection 4: Business Asset and Liability Information (Foreign and Domestic)16aCASH ON HAND Include cash that is not in the bankTotal Cash on Hand Contents16b Is there a safe on the business premisesYesNoBUSINESS BANK ACOUNTS Include online and mobile accounts (e.g., PayPal), money market accounts, savings accounts, checking accountsand stored value cards (e.g., payroll cards, government benefit cards, etc.)List safe deposit boxes including location, box number and value of contents. Attach list of contents.Type ofAccountFull Name and Address (Street, City, State, ZIP code) ofBank, Savings & Loan, Credit Union or Financial InstitutionAccount BalanceAccount NumberAs ofmmddyyyy17a 17b 17c 17d Total Cash in Banks (Add lines 17a through 17c and amounts from any attachments) Catalog Number 16649Pwww.irs.govForm 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)Page3ACCOUNTS/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). Include Federal, state and local government grants and contracts.Name & Address (Street, City, State, ZIP code)Status (e.g., age,factored, other)Date Due(mmddyyy)Invoice Number or GovernmentGrant or Contract NumberAmount Due18aContact NamePhone18b Contact NamePhone18c Contact NamePhone18d Contact NamePhone18e Contact NamePhone 18f Outstanding Balance (Add lines 18a through 18e and amounts from any attachments) INVESTMENTS List all investment assets below. Include stocks, bonds, mutual funds, stock options, certificates of deposit, commodities (e.g.,gold, silver, copper, etc.) and virtual currency (e.g., Bitcoin, Ripple and Litecoin).Name of Company & Address(Street, City, State, ZIP code)Used as collateralon loanEquityValue Minus LoanLoan BalanceCurrent Value19aYesNoPhone 19bYesPhoneNo19c Total Investments (Add lines 19a, 19b, and amounts from any attachments)AVAILABLE CREDIT Include all lines of credit and credit cards. Available CreditAmount OwedFull Name & Address (Street, City, State, ZIP code)Credit LimitAs ofAs ofmmddyyyymmddyyyy20aAccount No. Account No. 20b20c Total Credit Available (Add lines 20a, 20b, and amounts from any attachments)Catalog Number 16649Pwww.irs.gov Form 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)Page4REAL PROPERTY Include all real property and land contracts the business owns/leases/rents.Purchase/Lease Date(mmddyyyy)Current FairMarket Value(FMV)Current LoanBalanceAmount ofMonthlyPaymentDate of FinalPayment(mmddyyyy)EquityFMV Minus Loan21a Property Description Location (Street, City, State, ZIP code) and County Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and PhonePhone21b Property Description Location (Street, City, State, ZIP code) and County Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and PhonePhone21c Property Description Location (Street, City, State, ZIP code) and County Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and PhonePhone21d Property Description Location (Street, City, State, ZIP code) and County Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and PhonePhone21e Total 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, etc.Purchase/Lease Date(mmddyyyy)22a YearMileageCurrent FairMarket Value(FMV)Current LoanBalanceAmount ofMonthlyPaymentDate of FinalPayment(mmddyyyy)EquityFMV Minus LoanMake/ModelLicense/Tag Number Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone Vehicle Identification Number (VIN)Phone22b YearMileageMake/ModelLicense/Tag Number Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone Vehicle Identification Number (VIN)Phone22c YearMileageMake/ModelLicense/Tag Number Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone Vehicle Identification Number (VIN)Phone22d YearMileageMake/ModelLicense/Tag Number Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone Vehicle Identification Number (VIN)Phone22e Total Equity (Add lines 22a through 22d and amounts from any attachments)Catalog Number 16649Pwww.irs.gov Form 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)Page5BUSINESS EQUIPMENT AND INTANGIBLE ASSETS Include all machinery, equipment, merchandise inventory, and other assets in 23a through 23d. Listintangible assets in 23e through 23g (licenses, patents, logos, domain names, trademarks, copyrights, software, mining claims, goodwill and trade secrets.)Purchase/Lease Date(mmddyyyy)Current FairMarket Value(FMV)Current LoanBalanceAmount ofMonthlyPaymentDate of FinalPayment(mmddyyyy)EquityFMV Minus Loan23a Asset Description Location of asset (Street, City, State, ZIP code) and County Lender/Lessor Name, Address, (Street, City, State, ZIP code) and PhonePhone23b Asset Description Location of asset (Street, City, State, ZIP code) and County Lender/Lessor Name, Address, (Street, City, State, ZIP code) and PhonePhone23c Asset Description Location of asset (Street, City, State, ZIP code) and County Lender/Lessor Name, Address, (Street, City, State, ZIP code) and PhonePhone23d Asset Description Location of asset (Street, City, State, ZIP code) and County Lender/Lessor Name, Address, (Street, City, State, ZIP code) and PhonePhone23e Intangible Asset Description 23fIntangible Asset Description 23g Intangible Asset Description 23h Total Equity (Add lines 23a through 23g and amounts from any attachments)BUSINESS LIABILITIES Include notes and judgements not listed previously on this form.Business Liabilities24a Description:Secured/UnsecuredDate Pledged(mmddyyyy)Date of FinalPayment(mmddyyyy)PaymentAmount PhoneSecuredUnsecuredNameStreet AddressCity/State/ZIP code Phone24c Total Payments (Add lines 24a and 24b and amounts from any attachments)Catalog Number 16649PBalance OwedSecuredUnsecuredNameStreet AddressCity/State/ZIP code24b Description: www.irs.gov Form 433-B (Rev. 2-2019)

Form 433-B (Rev. 2-2019)Page6Section 5: Monthly Income/Expenses Statement for BusinessAccounting Method Used:CashAccrualUse the prior 3, 6, 9 or 12 month period to determine your typical business income and expenses.Income and Expenses during the period (mmddyyyy)to (mmddyyyy)Provide a breakdown below of your average monthly income and expenses, based on the period of time used above.Total Monthly Business Income2526272829Income SourceGross Receipts from Sales/ServicesGross Rental IncomeInterest IncomeDividendsCash Receipts (Not included in lines 25-28)Other Income (Specify below)303132333435 Total Income (Add lines 25 through 34)Total Monthly Business ExpensesGross Monthly3637383940414243444546474849 Expense itemsMaterials Purchased 1Inventory Purchased 2Gross Wages & SalariesRentSupplies 3Utilities/Telephone 4Vehicle Gasoline/OilRepairs & MaintenanceInsuranceCurrent Taxes 5Other Expenses (Specify)IRS Use Only-Allowable Installment PaymentsTotal Expenses (Add lines 36 through 47)Net Income (Line 35 minus Line 48)Actual Monthly 1 Materials Purchased: Materials are items directly related to theproduction of a product or service.4 Utilities/Telephone: Utilities include gas, electricity, water, oil, otherfuels, trash collection, telephone, cell phone and business internet.2 Inventory Purchased: Goods bought for resale.5 Current Taxes: Real estate, state, and local income tax, excise,franchise, occupational, personal property, sales and the employer'sportion of employment taxes.3 Supplies: Supplies are items used to conduct business and areconsumed or used up within one year. This could be the cost ofbooks, office supplies, professional equipment, etc.Certification: Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities, and otherinformation is true, correct, and complete.SignatureTitleDatePrint Name of Officer, Partner or LLC MemberAfter we review the completed Form 433-B, you may be asked to provide verification for the assets, encumbrances, income and expensesreported. Documentation may include previously filed income tax returns, profit and loss statements, bank and investment statements, loanstatements, financing statements, bills or statements for recurring expenses, etc.IRS USE ONLY (Notes)Privacy Act: The information requested on this Form is covered under Privacy Acts and Paperwork Reduction Notices which have already beenprovided to the taxpayer.Catalog Number 16649Pwww.irs.govForm 433-B (Rev. 2-2019)

Section 1: Business Information 1a Business Name 1b Business Street Address Mailing Address City StateZIP 1d 1c Business Telephone 1e Type of Business 1f Business Website (web address) County 2a Employer Identification No. (EIN) 2b Type of entity (Check appropriate box below) PartnershipCorporation Other