C58P 
Personal Financial Statement 

Complete each section of the financial statement. We use this information to determine your ability 
to pay. If you do not complete the financial statement, we may deny your request. 

The information you provide on this form is confidential. You are not legally required to provide this 
information, but we are legally allowed to request it. 

If a question does not apply to your situation, write “N/A” in the provided field. 

Personal Information 
Your Full Name                                         Spouse’s Full Name 

Your Social Security #        Your Birth Date          Spouse’s Social Security #        Spouse’s Birth Date 

Your Street Address                                    Spouse’s Street Address (if different than yours) 

City                                    State ZIP Code City                                    State     ZIP Code 

Home Phone                    Work Phone               Spouse’s Home Phone         Spouse’s Work Phone 

Total Number and Ages of People in Your Household 

Current Employment Information 
You (circle one):  Full-time  Part-time                Your Spouse (circle one):  Full-time    Part-time 

Employer or Business Name     Occupation               Employer or Business Name           Occupation 

Street Address                                         Street Address 

City                                    State ZIP Code City                                    State     ZIP Code 

Bank Accounts (credit unions, money market, stocks, bonds, 401(k)s, IRAs, etc.) 
                       Type of Account 
Name of Institution    (checking, savings,        Account Number   Name on Account             Balance/Value 
                       other – specify) 

                                                       Total Bank Accounts Balance/Value       $ 

Real Estate (home, vacant land, cabin, etc.) 
                                  County Where the       Mortgage          Current      Minimum Monthly 
Address 
                                  Property is located    Balance           Value        Payment 

                                  Total Real Estate Minimum Monthly Payment             $ 

Credit Cards (Visa, MasterCard, American Express, Discover, etc.) 
                                                                         Current        Minimum Monthly 
Card Name                                                Credit Limit 
                                                                         Balance        Payment 

                                  Total Credit Cards Minimum Monthly Payment            $ 

Motor Vehicles (cars, boats, RVs, motorcycles, snowmobiles, ATVs, etc.) 
                                                                                          Minimum 
                                                                   Balance       Payoff 
Year/Make               Model                Financed By                                  Monthly 
                                                                   Due           Date 
                                                                                          Payment 

                                  Total Motor Vehicles Minimum Monthly Payment            $ 

Living Expenses 

Taxes Withheld Federal/State/FICA                        Rent/Mortgage 

Child Support/Alimony                                    Association Fees 

Retirement/IRAs/401(k)s                                  Insurance Taxes 

Day Care                                                 Utilities 

Life Insurance                                           Phone 

Medical Insurance                                        Groceries 
Medical Expenses Not Paid by 
Insurance                                                Clothing/Personal Care Items 
Transportation 
Gas/Parking/Insurance/Bus                                Total Monthly Living Expenses    $ 

Other Obligations (home equity, personal loans, amounts owed to IRS, etc.) 
                                                                           Current           Minimum Monthly 
Type of Obligation                Payoff Date 
                                                                           Balance           Payment 

                                  Total Other Obligations Minimum Monthly Payment            $ 

                                  Combined Total of Monthly Expense Use your totals from the previous 
                                  sections to determine your total monthly expenses. 

                                  Total Minimum Monthly Credit Card Payments 

                                  Total Minimum Monthly Motor Vehicle Payments 

                                  Total Monthly Living Expenses 

                                  Total Minimum Monthly Other Obligation Payments 

                                                                 Total Monthly Expenses        $ 

Income Include income information for you and all other adults that live with you and help pay the household 
monthly expenses. Attach the two most recent pay stubs for each person. 
Your Gross Monthly Pay (wages,    Soc. Security/Retirement 
commissions, 1099, etc.) 
Spouse’s Gross Monthly Pay        Profit from Business 
(wages, commissions, 1099, etc.) 
                                  Other (unemployment, disability, 
Alimony/Child Support Paid to You etc.) 

Rent(s) Paid to You                                                     Total Monthly Income $ 

If there is other information you want us to consider, use this section to tell us. Attach 
additional paper if needed. 

Authorization 
The information I provided in this financial statement is accurate to the best of my knowledge 
and belief. I authorize the Minnesota Department of Revenue to verify any information on this 
form. I understand the department:  

        will review the information I have provided
        has the authority to approve or deny my request
        may ask me to provide additional documentation
        may use this information to collect my debt 

______________________________________________________________________________ 
   Signature                                                          Date 

______________________________________________________________________________ 
   Print your name 

If you are requesting a payment agreement, you must complete this section and provide your bank information 
or we cannot complete your application. 
If we accept the payment amount you are proposing, we will send you a letter explaining the 
terms of the payment agreement. 

We will withdraw payments directly from your bank account on or after the scheduled payment 
date using an electronic funds transfer (EFT).  

We add a nonrefundable $50 fee to payment agreements that include tax debt. Penalty                   and 
interest will accrue on all tax debt and some other types of debt until the balance is paid in full. 

Payment terms you are requesting 
I am requesting to pay the total debt as follows: 

                                                           st
Payment amount proposed $ _________________   Date of 1  payment _______________ 

Payment frequency (circle one):   Monthly               Biweekly                               Weekly 

Bank Information 
Withdraw my payments as specified above from the following bank 
account: 
Bank name __________________________________               Account # ____________________  

Name on account _____________________________              Routing # ____________________ 

Account type   (circle one): Checking   Savings   Account holder’s phone # ___________________ 

Will these payments come from a financial institution outside of the United States? (circle one) 
   Yes   No 

By providing a signature and Social Security number or FEIN for an authorized user of the account 
below, you authorize the Minnesota Department of Revenue to withdraw the payments as 
specified. 
Authorized signer name                            Social Security Number or FEIN