Form C58P, Personal Financial Statement 
Complete each section of this form. We use this information to determine your ability to pay. 
The information you provide is confidential and you are not required to provide it. However, if you do not complete 
the financial statement, we may deny your request.  
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 Number Your Birth Date          Spouse’s Social Security Number     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  Unemployed Your Spouse (circle one):  Full-Time   Part-Time  Unemployed 

Employer or Business Name   Occupation               Employer or Business Name           Occupation 

Street Address                                       Street Address 

City                                 State ZIP Code  City                                     State    ZIP Code 

Bank Accounts (Such as 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 $ 

 Virtual Currency (Crypt ocurrency)(Include Bitcoin, Ethereum, Litecoin, Ripple, etc.) 
 Type of      Name of Virtual Currency  Email Address Used to Set  Locations (Mobile Wallet,  Virtual Currency 
 Virtual      Wallet, Exchange, or Digital  up with the Virtual     Online, External Hardware  Amount and Value 
 Currency     Currency Exchange (DCE)   Currency Exchange or DCE  Storage)                          in US Dollars 

                                                                    Total Value of Virtual Currency $ 

 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 
                                                      Clothing/Personal Care Items 
 by Insurance 
 Transportation 
                                                                    Total Monthly Living Expenses  $ 
 Gas/Parking/Insurance/Bus 

 Real Estate (Include 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 (Such as Visa, MasterCard, American Express, Discover, etc.) 
 Card Name                  Credit Limit                         Current Balance          Minimum Monthly Payment 

                                        Total Credit Cards Minimum Monthly Payment   $ 

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

                                          Total Motor Vehicles Minimum Monthly Payment  $ 

 Other Obligations(Include 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, 
                                   Social Security/Retirement 
commissions, 1099, etc.) 
Spouse’s Gross Monthly Pay 
                                   Profit from Business 
(wages, commissions, 1099, etc.) 
 Alimony/Child Support Paid to You Other (unemployment, disability, etc.) 

 Rent 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 provided
•         Has the authority to approve or deny my request
•         May ask me to provide more 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 your proposed payment amount, 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. 
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: 

Payment amount proposed $                         Date of first 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 Federal Employer Identification Number 
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