Form TTB F 5600.18 TTB F 5600.18 Collection Information Statement for Businesses

OMB NO. 1513-0054 (01/31/2011)
DEPARTMENT OF THE TREASURY – ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
COLLECTION INFORMATION STATEMENT FOR BUSINESSES
(If you need additional space, please attach a separate sheet)
Section 1
Business
Information

1a. Business Name

3a. Contact Name

Business Street Address

3b. Contact’s Business Telephone(

)

-

Extension
City

State

Best Time To Call

Zip

1b. Business Telephone

(

)

-

Best Time To Call

2a. Employer Identification No. (EIN)

Section 2
Business
Personnel
and Contacts

-

Corporation

am

)

-

pm (Enter Hours)

3d Contact’s Other Telephone (

)

-

Telephone Type (i.e. fax, cellular, pager)

2b. Type of Entity (Check appropriate box below)
Partnership

pm (Enter Hours)

3c. Contact’s Home Telephone (

County

Check this
box when all
spaces in
Sect 1 are
filled in.

am

Other

2c. Type of Business

3e Contact’s E-Mail Address

4. PERSON RESPONSIBLE FOR DEPOSITING PAYROLL TAXES
4a.Full Name

Title

Social Security Number

Home Street Address
City

Home Telephone Number
State

(

-

)

Ownership Percentage & Shares of Interest

Zip

5. PARTNERS, OFFICERS, MAJOR SHAREHOLDERS, ETC.
5a.Full Name

Title

Social Security Number

Home Street Address
City
5b. Full Name

Home Telephone Number
State
Title

Social Security Number

Check this
box when all
spaces in
Sect 2 are
filled in.

Home Telephone Number
State
Title

5d. Full Name

Title

(

)

(

Social Security Number
Home Telephone Number

State

-

-

)

-

Ownership Percentage & Shares of Interest

Zip

Home Street Address
City

-

Social Security Number
Home Telephone Number

State

)

Ownership Percentage & Shares of Interest

Zip

Home Street Address
City

(

-

Ownership Percentage & Shares of Interest

Zip

Home Street Address
City
5c. Full Name

-

(

)

-

Ownership Percentage & Shares of Interest

Zip

Section 3
Accounts/
Notes
Receivables

6. ACCOUNTS/NOTES RECEIVABLE. List all contracts separately, including contracts awarded, but not started.

See page 6
for additional
space, if
needed

Street Address

30 -- 60 days

City/State/Zip

60 -- 90 days

Check this
box when all
spaces in
Sect 3 are
filled in.

Description

Amount Due

6a.Name

$

Date Due

Age of Account
0 -- 30 days

90 + days
6b.Name

$

0 -- 30 days

Street Address

30 -- 60 days

City/State/Zip

60 -- 90 days

6a + 6b = 6c (Transfer to page 6 if used)

TTB F 5600.18 (03/2008)

$ 0.00
Page 1 of 6

90 + days
Section 4 begins on page 2

COLLECTION INFORMATION STATEMENT FOR BUSINESS
BUSINESS NAME
Section 4
Other
Financial
Information

7.

EIN

-

OTHER FINANCIAL INFORMATION. Respond to the following business financial questions.

7a. Does this business have other business relationships (e.g. subsidiary or parent, corporation, partnership, etc.)?
NO

YES
If yes, list related EIN

-

Additional EIN

-

7b. Does anyone (e.g. officer, stockholder, partner, or employees) have an outstanding loan borrowed from the business?
If yes, amount of loan $

Date of Loan

Current Balance $

7c. Are there any judgments or liens against your business?
If yes, who is the creditor?

Date of judgment/lien

Amount of debt $

7d. Is your business a party in a lawsuit?
If yes, amount of suit $

Possible completion date

Subject matter of suit

Date discharged

Petition No.

7e. Has your business ever filed bankruptcy?
If yes, date filed

7f. In the past 10 years have you transferred any assets from your business name for less than their actual value?
If yes, what asset?

Value of asset at time of transfer $

When was it transferred?

To whom or where was it transferred?

7g. Do you anticipate any increase in business income (e.g. contracts bid but not yet awarded)?
If yes, why will the income increase?
Check
this box
when all
spaces in
Sect. 4 are
filled in.
Section 5
Business
Assets
Current
Value:
Indicate the
amount you
could sell the
asset for
today.

(Attach sheet if you need additional space.)

How much will it increase?

When will the business income increase?

7h. Is your business a beneficiary of a trust, an estate, or a life insurance policy?
If yes, name of the trust, estate, or policy?

Anticipated amount to be received?

When will the amount be received?
8. PURCHASED AUTOMOBILES, TRUCKS, AND OTHER LICENSED ASSETS. Include boats, RVs, motorcycles, trailers,
etc.
(If you need additional space, attach a separate sheet.)
Amount of
Description
Current
Loan
Name of
Purchase
Monthly
(Year, Make, Model, Mileage)
Value
Balance
Lender
Date
Payment
8a. Year
Make/Model
Mileage

$

$

$

$

$

$

8b. Year
Make/Model
Mileage
8c. Year
Make/Model
Mileage

9. LEASED AUTOMOBILES, TRUCKS, AND OTHER LICENSED ASSETS. Include boats, RVs motorcycles, trailers, etc.
(If you need additional space, attach a separate sheet.)
Amount of
Description
Lease
Name
Lease
Monthly
(Year, Make, Model)
Balance
of Lesser
Date
Payment
9a.Year
Make/Model
9b.Year
Make/Model

Section 5 continued on page 3

Page 2 of 6

TTB F 5600.18 (03/2008)

COLLECTION INFORMATION STATEMENT FOR BUSINESSES
BUSINESS NAME
Section 5
continued

Current
value
Indicate the
amount you
could sell the
asset for
today.

Date of
Final
Payment:
Enter the
date the loan
or lease will
be fully paid.

Check this
box if you are
attaching a
depreciation
schedule for
machinery/
equipment in
lieu of
completing
line 11.

Check this
box when all
spaces in
Sect. 5 are
filled in and
attachments
provided.

EIN

-

10. REAL ESTATE. List all real estate owned by the business.
(If you need additional space, attach a separate sheet.)
Street, Address,
City, State, Zip, and
County

Date
Purchased

Purchase
Price

Current
Value

Loan
Value

Name of
Lender or
Lien Holder

Amount of
Monthly
Payment

Date
of Final
Payment

10a.

$

$

$

$

$

$

$

$

10b.

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly
payment amount and current balance for each piece of real estate owned.
11. BUSINESS ASSETS. List all business assets and encumbrances below; include Uniform Commercial Code (UCC)
filings. (If you need additional space, attach a separate sheet.) NOTE: If attaching a depreciation schedule, the
attachment must include all of the information requested below.
Current
Value

Description
11a.

Loan
Balance

Amount of
Monthly
Payment

Name of Lender

Machinery
$

11c.

Equipment

11d.

Merchandise

11e.

Other Assets: (List Below)

$

Date
of Final
Payment

$

ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly
payment amount and current loan balance for assets listed which have an encumbrance.
Section 6
Investment,
Banking and
Cash
Information

12. INVESTMENTS. List all investment assets below. Include stocks, bonds, mutual funds, stock options, and certificates of
deposit
Name of Company

Number of
Shares/Units

Current Value

Loan
Amount

Used as collateral
on loan?

12a.

$

$

NO

YES

12b.

$

$

NO

YES

12c. Total Investments $

TTB F 5600.18 (03/2008)

Page 3 of 6

Section 6 continued on page 4

COLLECTION INFORMATION STATEMENT FOR BUSINESSES
BUSINESS NAME
Section 6
Continued
Complete
all entry
spaces with
the most
current data
available.

EIN

-

13. BANK ACCOUNTS. List all checking and savings accounts. (If you need additional space, attach a separate
sheet.)
Type of
Full Name of Bank, Saving & Loan,
Bank
Bank
Current
Account
Credit Union, or Financial Institution
Routing No.
Account No.
Account
Balance
Name
13a.
Checking
$
Street Address
City/State/Zip
13b.

Checking

Name

$

Street Address
City/State/Zip
13c.

Savings

Name

$

Street Address
City/State/Zip

$ 0.00

13d. Total Bank Account Balances

ATTACHMENTS REQUIRED: Please include your current bank statements (checking and savings)
for the past three months for all accounts.
14. OTHER ACCOUNTS. List all accounts including brokerage accounts, money market, additional checking,
and saving accounts not listed on line #13 and any other accounts not listed in this section.
Type of
Full Name of Bank, Saving & Loan,
Bank
Bank
Current
Account
Credit Union, or Financial Institution
Routing No.
Account No.
Account
Balance
Name
14a.
$
Street Address
City/State/Zip
Name

14b.

$

Street Address
City/State/Zip

$ 0.00

14c. Total Other Account Balances

ATTACHMENTS REQUIRED: Please include your current bank statements (checking, savings,
money market, and brokerage accounts) for the past three months for all accounts.
15. CASH ON HAND. Include any money that you have that is not in the bank.
15a. Total Cash on Hand $
16. AVAILABLE CREDIT. List all lines of credit, including credit cards.
Full Name of Credit Institution
Credit Limit
Amount Owed
Available Credit
Name
$
16a.
Check
this box
when all
spaces in
Sect. 6 are
filled in and
attachment
s provided.

Street Address
City/State/Zip
16b.

Name

$

Street Address
City/State/Zip

Section 7 continued on page 5

16c. Total Credit Available

Page 4 of 6

$ 0.00

TTB F 5600.18 (03/2008)

COLLECTION INFORMATION STATEMENT FOR BUSINESS
BUSINESS NAME
Section 7
Monthly
Income and
Expenses
Complete
all entry
spaces with
the most
current data
available.

17.

EIN

The following information applies to income and expenses from your most recently filed Form 1120 or Form 1065.
Fiscal Year Period

18.

-

From:

Accounting Method Used:

To:
Cash

Accrual

The information included on lines 19 through 39 should reconcile to your business federal tax return.
TOTAL INCOME

TOTAL EXPENSES

Source

Gross Monthly

Expense Items

Actual Monthly

19. Gross Receipts

$

27. Materials Purchased (1)

$

20. Gross Rental Income

28. Inventory Purchased (2)

21. Interest

29. Gross Wages & Salary

22. Dividends

30. Rent

Other Income (specify in lines 23-25)

31. Supplies (3)

23.

32. Utilities/Telephone (4)

24.

33. Vehicle Gasoline/Oil

25.

34. Repairs & Maintenance

(Add lines 19 through 25)

35. Insurance

26. TOTAL INCOME

0.00

36. Current Taxes (5)
Other Expenses (Include installment
payments, specify in lines 37-38)
37.
38.
(Add lines 27 through 38)
39. Total Expenses

0.00

(1) Material Purchased: Materials are items directly related to the production of a product or service.
(2) Inventory Purchased: Goods bought for resale.
(3) Supplies: Supplies are items used in your business that are consumed or used up within one year, this could be the
cost of books, office supplies, professional instruments, etc.
(4) Utilities: Utilities include gas, electricity, water, fuel, oil, other fuels, trash collection, and telephone.
Check
this box
when all
spaces in
Sect. 7 are
filled in.
Check
this box
when all
spaces in
all sections
are filled in
and all
attachments
provided.

(5) Current Taxes: Real estate, state and local income tax, excise, franchise, occupational, personal property, sales,
and the employer’s portion of employment taxes.

CAUTION
Failure to complete all entry spaces may result in rejection or significant delay in the resolution of your accounts.
Certification: Under penalties of perjury, I declare that to the best of my knowledge and belief this
statement of assets, liabilities, and other information is true, correct, and complete.
Print Name

Title

Your Signature

Date

TTB F 5600.18 (03/2008)

Page 5 of 6

Accounts/Notes Receivable Continuation page 6

COLLECTION INFORMATION STATEMENT FOR BUSINESS
BUSINESS NAME
Section 3
Accounts/
Notes
Receivable
continued

EIN

-

ACCOUNTS/NOTES RECEIVABLE CONTINUATION PAGE. List all contracts separately, including contracts awarded, but
not started. (If you need additional space, copy this page and attach to TTB F 5600.18 form)
Description

Amount Due

Date Due

Age of Account
0 -- 30 days

Use only if
needed.

Check
this box if
this page is
not needed.

6d.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days
0 -- 30 days

6e.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days
0 -- 30 days

6f.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days
0 -- 30 days

6g.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days
0 -- 30 days

6h.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days
0 -- 30 days

6i.Name

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days
0 -- 30 days

6j.Name

Check
this box
when all
spaces in
Sect. 3 are
filled in.

$

30 -- 60 days

Street Address

60 -- 90 days

City/State/Zip

90 + days

Add Lines 6d through 6j = 6k

0.00

Transfer from Page 1 line 6c

0.00

6l Total Accounts/Notes Receivable 6k + 6c

0.00

Page 6 of 6

TTB F 5600.18 (03/2008)