Business Financial Statement                                                                               C58B 

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. 

 Who is filling out this form? 
 Your Full Name and Title                       Work Phone                 Your Email Address 

 Business Information 
 Business Name                                       Business Phone                  Business Web Address 

 Physical Address of the Business                    Mailing Address of the Business (if different) 

 Minnesota Tax Identification Number                 Federal Employer Identification Number (FEIN) 

 Type of Business (include a brief description) 

 Licenses (List all active licenses held by this business, partners, officers, or owners to conduct a profession, occupation, 
 trade, or business.) 
 Issued To                 License Title             Issuing Authority               Renewal Date 

 Business Bank Accounts   (List all active checking, savings, money market accounts, etc.) 
                                                                                                    Current 
 Account Type         Financial Institution Name and Address               Account Number 
                                                                                                    Balance 

                                                                           Total Cash on Hand       $ 

Individuals of Authority(Include all owners, officers, and partners for this business. Attach additional paper if needed.) 

Name (first and last)                        Home Phone                                Cell Phone 

Home Address                                 Social Security Number 

                                             Position Held Within the Business 

                                             From          To                          Total Shares/Interest 

Name (first and last)                        Home Phone                                Cell Phone 

Home Address                                 Social Security Number 

                                             Position Held Within the Business 

                                             From          To                          Total Shares/Interest 

Name (first and last)                        Home Phone                                Cell Phone 

Home Address                                 Social Security Number 

                                             Position Held Within the Business 

                                             From          To                          Total Shares/Interest 

Which payment processors and credit cards do you accept? 
Payment Processor Name (First Data,  Payment Processor 
                                                                        Payment Processor Address 
PayPal, Google Checkout, etc.)       Account Number  

Credit Card Name (Visa, MasterCard,  Merchant Account                   Merchant Account Provider, Name, and 
American Express, etc.)              Number                             Address 

 Credit Available List all credit cards, open lines of credit, etc. 
 Account or                                                          Credit  Current  Available 
                  Credit Institution Name and Address 
 Card Type                                                           Limit   Balance  Credit 
                                                                                       
                                                                      Total Available Credit  $ 
 
 Accounts Receivable and Loans Owed to the Business Include all other businesses and individuals 
 that owe this business money. 
 Business or Individual Name and Address       Phone                       Due Date   Amount Due  
                                                                                       
                                                                      Total Amount Due   $ 
 
 Investments stocks, bonds, mutual funds, etc. 
                                               Used as 
                                                                    Current Loan 
 Investment Company Name and Address           Collateral?                           Cash-in Value 
                                                                    Value   Balance 
                                               (circle one) 
                                                                                      
                                               Yes     No 
                                                                                      
                                               Yes     No 
                                                                                      
                                               Yes     No 
                                                                                      
                                               Yes     No 

                                                                      Total Cash-in Value   $ 

 Real Estate Owned by the Business (commercial, residential, vacant land, etc.) 
                                                  Fair Market            Current Loan Monthly 
 Property Address 
                                                  Value                  Balance      Payment 
                                                                                       
                                     Total Monthly Real Estate Payments  $ 
 
 Motor Vehicles (cars, boats, RVs, motorcycles, snowmobiles, ATVs, etc.) 
                                    Outstanding                                       Monthly 
 Year  Make and Model                              Finance Company                             
                                    Loan Balance                                      Payment 
                                                                                       
                                     Total Monthly Motor Vehicle Payments  $ 
 
 Business Equipment (machinery, inventory, merchandise, etc.) 
                                    Outstanding                                       Monthly 
 Year  Make and Model                              Finance Company                             
                                    Loan Balance                                      Payment 
                                                                                       
                                    Total Monthly Business Equipment Payments  $ 
 
 If there is other information you want us to consider, use this section to tell us. 
 Attach additional paper if needed. 
  

Income Statement (12-Month Period) 

If this income statement does not fully reflect your business’ financial operations, you may include additional 
financial documents.  

Date Range From: _____________ To: _____________ 
 
Income                                          Expenses 
                                                                      1
Gross Receipts        $                         Materials Purchased       $ 
Gross Rental Income                             Inventory Purchased 2      
Interest                                        Gross Wages & Salaries     
Dividends                                       Rent                       
                                                          3
Cash                                            Supplies                   
Other Income (specify                                           4
                                                Utilities/Telephone        
below) 
                                                Vehicle Gasoline/Oil       
                                                Repairs and Maintenance    
                                                Insurance                  
                                                           5
                                                Current Taxes              
                                                Notes or Loan Payments     
                                                Other (specify below)      
                                                                           
       Total Income   $                         Total Expenses            $ 
 
                                                          Total Income  $ 
                                                 – Total Expenses  $ 
                                                 = Net Profit/Loss     $ 
 
1 
  Materials Purchased. Includes items directly related to the production of a product or service. 
2 
  Inventory Purchased. Includes goods bought for resale. 
3 
  Supplies. Includes items used to conduct business and consumed or used up within one year 
  (books, office supplies, professional equipment, etc.). 
4 
  Utilities/Telephone. Includes gas, electricity, water, oil, other fuels, trash collection, 
  telephone, cell phone, and business internet. 
5 
  Current Taxes. Do not include past-due taxes not paid, such as those included in this pay plan 
  application. 

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                                         Print your name 
____________________________________________________________________________ 
    Title                                             Date 
 
If you are requesting a payment agreement, you must complete this section and provide your bank 
information or we cannot complete your request. 
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 be sent 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