Compromise Application
Instructions
Your request for compromise includes a questionnaire and financial statement. You must complete and return the entire application, including any supporting information requested, before we will consider your request.
We will review and verify your documentation. We may need to contact you to discuss the information you submitted. We will notify you in writing when a decision is made. Allow 90 days for a response.
If you are seeking a compromise for a jointly filed debt, either:
Both filers seek a compromise together. Complete the entire application together. We use assets and income from both filers to approve or deny your request.
The filer seeking the compromise must first request a Separation of Liability. If the liability is separated, the compromise will be for only those debts remaining in your name.
Your completed application must also include:
Non-refundable application payment
There is a $250 nonrefundable payment due when you apply. We apply this payment to your debt.
If you cannot afford the payment, we may waive it if you meet at least one of these conditions:
Your income was less than 200% of the federal poverty level
You were affected by the pandemic and unable to pay for necessities, including utilities, mortgage or rent, or needed medication
Complete the questionnaire stating you meet either of these conditions. If we deny your waiver request, you must make the payment before we review your application.
Make your check payable to the Commissioner of Revenue.
Current lease or rental agreements
Attach all lease agreements, including property where you are the lessor or lessee.
Medical documentation
Attach physician’s letters or other documents to show any medical condition that should be considered.
Power of Attorney
Attach a power of attorney form if this offer is submitted by a designated representative. Send all required information and your $250 payment to:
Minnesota Revenue PO Box 64447-CMP
St. Paul, MN 55164-0447
Keep a copy of all the information you provide us for your records.
Compromise Questionnaire
Your name: Your Social Security Number: We use this information to evaluate your ability to pay and to decide if a compromise is in the best interest of the State of Minnesota. This information may be used for collection purposes. You are not legally required to provide the information requested; however, if no information is provided or if the information is insufficient to make a determination , we will deny your request. (If you need more room to answer any of the questions, please use the back of this questionnaire.)
What is the maximum amount you can pay for a lump-sum settlement of your debt? $
4795520 228600 0 0 5208905 228600 0 0 Where will you obtain the funds?
Have you sold, transferred, or gifted any real estate during the past two years? Yes No
If yes, list property address, include the property identification numbers, and attach documentation
684530 173990 0 0
4462780 6985 0 0 4876165 6985 0 0 Do you plan to buy, sell, or refinance real estate in the next three years? Yes No
If yes, explain:
What caused your large tax liability? (Example: cashing of 401k or stocks, claiming the wrong number of exemptions, etc.)
684530 188595 Do you foresee having problems meeting future tax obligations? Yes
No
0 0 Do you foresee having problems meeting future tax obligations? Yes
No
If no, what has changed or been corrected?
If you are currently unemployed, what are your long-term job prospects?
687070 189230 0 0
Do you have any health issues that prevent you from working? Explain and attach current documentation.
687070 193675 0 0
4505325 114300 0 0 4003040 114300 0 0
If business taxes are owed, what is the status of your business?
Open
Closed
4190365 227330 0 0 4603750 227330 0 0 If closed, what date did it close? Minnesota Tax Identification Number
Is anyone holding assets on your behalf (e.g., trust fund, property)? Yes No
I f yes, identify type of assets and value:
687070 179705 0 0
Relationship to asset holder:
Is a foreclosure pending on any real estate you own or have an interest in?
5167630 229235 0 0 5581015 229235 0 0 I f yes, explain:
Is there a likelihood that you will receive assets or income from an estate in probate? Yes No
4664075 253365 0 0 5077460 253365 0 0 If yes, from whom? Relationship:
Do you anticipate any increase in household income in the next two years? Yes No
If yes, explain:
495300 620395 0 0 Why do you believe it is in the State’s best interest to settle your account for less than the full amount due?
687070 173355 0 0 687070 380365 0 0
I cannot afford the $250 payment. I request a waiver because my conditions meet the financial requirements laid out in the instructions.
Your signature
Date
Daytime phone
Spouse’s signature
Date
Daytime phone
768985 3702685 0 0 1416685 3702685 0 0 4197985 3702685 0 0 4845685 3702685 0 0 768985 3855085 0 0 1416685 3855085 0 0 2331085 3855085 0 0 2902585 3855085 0 0 4197985 3855085 0 0 4845685 3855085 0 0 5760085 3855085 0 0 6331585 3855085 0 0
Individual Financial Statement for Offer in Compromise
This information may be used for collection purposes. We may require Social Security numbers under 42 USC 405 (c) (2) (C) ( i ). You are not legally required to provide the information requested. However, if you do not provide enough information, we may deny your request. Include all household income and expenses even if only one person is liable for the tax.
Section 1—General Information
Your Name
Spouse’s Name
Your Social Security Number Your Date of Birth
Spouse’s Social Security Number
Spouse’s Date of Birth
Your Address
Own
Rent
Spouse’s Address (if different)
Own
Rent
City
County
State
ZIP Code
City
County
State ZIP Code
Home Phone Number Work Phone Number
Spouse’s Home Phone Number
Spouse’s Work Phone Number
You
Full-Time
Part-Time
Spouse
Full-Time
Part-Time
Employee
Sole Proprietor
Partner Officer
Employee
Sole Proprietor
Partner Officer
Your Employer or Business Name
Occupation
Spouse’s Employer or Business Name
Occupation
Address
Address
City
State
Zip Code
City
State
ZIP Code
Length of employment (years/months)
Length of employment (years/months)
Paid Weekly Bi-weekly Semi-monthly Monthly
Paid Weekly Bi-weekly Semi-monthly Monthly
Highest level of education attained?
Highest level of education attained?
Professional License
Renewal Dates
Spouse’s Professional Licenses
Renewal Dates
Year of Last Filed Income Tax Return
Federal
State
Year of Last Filed Income Tax Return
Federal
State
Allowances Claimed on W4
Allowances Claimed on W4
Personal Representative/Tax Preparer (Attach Power of Attorney Form REV184)
Personal Representative/Tax Preparer (Attach Power of Attorney Form REV184)
Address
Address
City State
ZIP Code
Phone Number
City State
ZIP Code
Phone Number
Section 2—Asset Information
Bank and Credit Union Accounts (checking, savings, CDs, etc.) Attach copies of savings and checking account bank statements for the last three months.
Name of Institution
Address
Type of Account
Account Number
Balance
Total bank assets
$
Investments (stocks, bonds, mutual funds, retirement accounts, government securities, money market funds, etc.) Attach copies of most current statements.
Type of Investment
Issuer
Quantity
Current Value
Total Investments
$
Real estate (personal residence, vacation or second home, investment property, land, etc.). Attach most current property tax statements and homeowner’s insurance policy.
Description
Address
City
State
Current Market Value
Amount Owed
Equity in Property
Total Real Estate Equity
$
Motor Vehicles (cars, trucks, RVs, campers, motorcycles, boats, trailers, snowmobiles, ATVs, etc.) Attach additional sheets if necessary.
Make
Model
Year
Amount Owed
Payoff Date
Minimum Monthly Payment
Equity in Vehicle
Total Vehicle Equity
$
Other Assets
Current Value
Cash surrender value of life insurance
Judgements or settlements received
Notes receivable
Other (specify)
Total Other Assets
$
Section 3—Liability Information
(not included in assets previously listed) . Attach copies of most current billing statements showing monthly payments, loan payoffs, balances, and recent activity. Include three months of the most recent statements available.
Credit Cards (Visa, MasterCard, American Express, Discover, etc.)
Card Name Credit Limit Current Balance Minimum Monthly Payment
Total Credit Payments
$
Other Liabilities
Personal Loans, Judgments or Notes Payable
Type of Liability Current Balance Minimum Monthly Payment
Bank Line of Credit
State Agency or Local Tax Debts
Federal Tax Debts
Total Liability Payments
$
If you owe past due federal tax, is this debt currently under levy by IRS?
Do you have an offer in compromise pending with the IRS?
Yes Yes
No If yes, what amount? No If yes, what amount?
Section 4—Income
Monthly Income
List all household income, including members of the household who may not be liable for the tax debt. Include the two most recent paystubs or earning statements and the most recent statement for all income.
If you cannot obtain paystubs, we will accept a recent W2 or 1099, bank statements showing direct deposits, or documents from your employer showing the required information.
Source
You
Spouse
Salary, wages, and tips
Overtime, bonuses, and commissions
Self-employment income
(net profit from Schedule C or Schedule C-EZ divided by 12)
Pensions, disability, and Social Security
Dividend, interest, and investment income
(include any from a related partnership, corporation, LLC, LLP, etc.)
Rental income
Estate, trust, and royalty income
Workers compensation and unemployment
Alimony and child support
Rent subsidies
Other (specify)
Monthly Income
Household income
List all people living in the household other than your spouse. All income earners in the household must provide current copies of the most recent statement from all sources of income.
Total number of people in your household
Name
Relationship to you
(partner, roommate, parent, etc.)
Age
Income contributed
Household Income
Monthly Income
Total Household Income
$
Monthly Expenses
If you are self-employed, do not include expenses claimed on Schedule C.
Include copies of statements for the last three months. You must explain which member of your household is responsible for paying each expense
Source
Amount
Essentials
Groceries
Clothing and personal care
Housing cost
Mortgage or rent payments
Utilities
Electric
Water or Sewer
Phone
Garbage
Gas or oil for heating
Internet
Transportation
*Vehicle payments
Transportation (gas/oil, license, bus fare, etc.)
Miles driven to and from work per week
Insurance
Life insurance
Auto insurance
Health insurance
Home insurance
Tax liabilities
Income taxes (federal/state/SS/FICA )
Estimated quarterly tax payments (divide by three to get monthly amount)
Property tax
Other expenses
*Court ordered payment (child support, alimony, etc.)
*Childcare
*Other (specify)
Monthly expenses
Total Credit Payments from Section 3
Total Liability Payments from Section 3
Total Expenses
Net disposable monthly income (subtract “Total expenses” from “Total household income”)
I declare that the information in this statement is true and correct to the best of my knowledge and belief. I authorize the Department of Revenue to verify any information on this form.
365125 95250 0 0
Your signature Date Spouse’s signature Date
The information you provide on this form is confidential. It can only be given to the Internal Revenue Service, other states, Minnesota municipalities, the Minnesota Attorney General in the administration of tax laws, the Minnesota Department of Human Services if there is any evidence you have deserted your children or are delinquent in child support payments, or another person who must list some or all of your income or expenses on his or her tax return.
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