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:
Nonrefundable 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 have a financial hardship 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 pay-
ment 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.
Other documentation
Provide supporting documentation for any other circumstances or expenses that may prevent you from paying your debt in full, such 
as medical expenses, child support, or court-ordered payments.
Power of Attorney
If this offer is submitted by a designated representative, attach a power of attorney form.  

Send all required information and your $250 nonrefundable payment to:
  Minnesota Department of Revenue
  PO Box 64447-CMP
  St. Paul, MN 55164-0447
Send Electronically
You may submit your compromise agreement, additional documentation, and application payment online.  
Go to www.revenue.state.mn.us and enter compromise into the Search box.  
Keep a copy of all the information you provide us for your records.

Rev. 4/23

Compromise Questionnaire

Your Name                                                                             Your Social Security Number                                
We use this information to evaluate your ability to pay and to decide if a compromise represents the most we can expect to collect. This information may 
be used for collection purposes. You are not legally required to provide the information requested. However, if you do not provide the information or the 
information is insufficient for us 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.
1. What is the maximum amount you can pay for a lump-sum settlement of your debt?    ..... ....... .... ....... ..... $                                      
   Where will you obtain the funds?  

2. 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.  
 
3. Do you plan to buy, sell or refinance real estate in the next three years? ... ...... ..... ....... ..... ...... ..... ..... .....    Yes      No 
   If yes, explain: 
4. What caused your large tax liability? (Example: cashing of 401k or stocks, claiming the wrong number of exemptions, etc.) 
 
   Do you foresee having problems meeting future tax obligations?  ... ...... ..... ....... ..... ...... ..... ..... ...... .....        Yes      No
   If no, what has changed or been corrected? 
5. If you are currently unemployed, what are your long-term job prospects?
 
   Do you have any health issues that prevent you from working? Explain and attach current documentation  .... ...... ...... ....        Yes      No
 
6. If business taxes are owed, what is the status of your business?  ..... ...... ..... ...... ...... ...... ..... ...... ..... ....     Open     Closed
   If closed, what date did it close?             Minnesota Tax Identification Number 

7. Is anyone holding assets on your behalf (e.g., trust fund, property)?  .... ...... ..... ...... ..... ..... ...... ...... ...... .    Yes      No
   If yes, identify type of assets and value: 
   Relationship to asset holder: 

8. Is a foreclosure pending on any real estate you own or have an interest in?... ...... ..... ....... ..... ...... ..... ..... ...      Yes      No
   If yes, explain: 

9. Is there a likelihood that you will receive assets or income from an estate in probate?  .. ..... ...... ....... ..... ...... ....    Yes      No
   If yes, from whom?                              Relationship 
                                                                                                                               
10.  Do you expect any increase in household income in the next two years?   . ..... ...... ..... ...... ...... ..... ...... ..... .     Yes      No
   If yes, explain: 
11.  How did you determine your compromise offer and why is a compromise the best way to settle your tax liability?
 
    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

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 re-
quired 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 First Name and Middle Initial         Your Last Name                     Spouse’s First Name and Middle Initial    Spouse’s Last Name

Your Social Security Number                Your Date of Birth                 Spouse’s Social Security Number           Spouse’s Date of Birth

Your Address                                                                  Spouse’s Address (if different) 
                                               Own            Rent                                                            Own           Rent
City                                       State    ZIP Code                  City                                      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 
Employer or Business Name                  Occupation                         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          Professional License                                    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 REV184i)  Personal Representative/Tax Preparer (Attach Power of Attorney Form REV184i) 

Address                                                                       Address

City                                 State    ZIP Code    Phone Number        City                               State  ZIP Code      Phone Number

(Rev. 4/23)

Individual Financial Statement for Offer in Compromise, page 2

Section 2 — Income
List all income. 
Include the two most recent paystubs or earning statements and the most recent statement for all other 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.
Monthly Income Source (Attach two current paystubs)                                You                           Your Spouse
Salary, wages, tips 
Overtime, bonuses, 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
                                                    Monthly Income Totals
                    Combined Income (Your monthly total income plus your spouse’s monthly total income)

Section 3 — Asset Information
Bank 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 Investment Value
Real Estate (personal residence, vacation or second home, investment property, land, etc.).  
Attach most current property tax statements and homeowner’s insurance policy.
Address                                  County Where       Mortgage Balance       Current Value                 Minimum Monthly Payment
                                         Property is Located

                                                            Total Real Estate Minimum Monthly Payment

Individual Financial Statement for Offer in Compromise, page 3
Motor Vehicles
Make                Model             Year Amount Owed           Payoff Date                  Minimum Monthly Payment Equity in Vehicle

                                                                                              Total Vehicle Equity
Other Assets                                                                                                                                
Type of Asset                                                                                                         Current Value
Cash surrender value of life insurance
Judgments or settlements receivable
Notes receivable
Other (Specify)

                                                                                              Total Other Assets

Section 4 — 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 Lines of Credit
Type of Liability                                                             Current Balance      Minimum Monthly Payment

Individual Financial Statement for Offer in Compromise, page 4

State Agency or Local Tax Debts
Type of Liability                                          Current Balance                        Minimum Monthly Payment

Federal Tax Debts
Type of Liability                                          Current Balance                        Minimum Monthly Payment

                                                                        Total Liability Payments

If you owe past due federal tax, is this debt currently under levy by the IRS?  Yes      No       If yes, what amount? 

Do you have an offer in compromise pending with the IRS?                        Yes      No       If yes, what amount? 

Section 5 — Household Expenses
Household
Total number of people in your household: 
List all people living in the household other than your spouse who contribute to paying expenses. 
Name                                                       Relationship to You (Partner, Roommmate, Parent, Other) Age

Monthly Expenses
List all monthly household expenses. You must show which member of your household pays each expense. Include copies of statements for any 
expenses over the federal and state expense guidelines based on your most recent family size.  
If you are self-employed, do not include expenses claimed on Schedule C.
Total number of people in your family (self, spouse, dependents, etc.): 

Source                                                                                                                 Amount
Essentials
Groceries
Clothing and personal care
Housing Cost
Mortgage or rent payments

Individual Financial Statement for Offer in Compromise, page 5

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
Health Insurance
Auto 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
Medical expenses and prescriptions not paid by insurance (Attach copies of billing statements for 3 months)
Court ordered payments (child support, alimony, etc.) (Attach copies of billing statements for 3 months)
Child care (Attach copies of billing statements for 3 months)
Other (Specify) 
                                                                                   Total Monthly Expenses
                                                                        Total Liability Payments (from Section 4) 
                                    Total Expenses (Add Total Monthly Expenses and Total Liability Payments)
                       Net Disposable Monthly Income (subtract Total Expenses from Total Income in Section 2)

I declare that the information in this statement is true and correct to the best of my knowledge and belief. I authorize the Minnesota Department of 
Revenue to verify any information on this form.
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.