Minnesota Personal Financial Statement

Personal Financial Statement
Form C58P, Personal Financial Statement
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
Your Social Security Number

Spouse’s Full Name
Your Birth Date

Spouse’s Social Security Number

Your Street Address

Spouse’s Street Address (if different than yours)

City
Home Phone

Spouse’s Birth Date

State

ZIP Code

Work Phone

City

State

Spouse’s Home Phone

ZIP Code

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

Employer or Business Name

Occupation

Street Address
City

Occupation

Street Address
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,
other – specify)

Account Number

Name on Account

Balance/Value

Total Bank Accounts Balance/Value $

Virtual Currency (Cryptocurrency)(Include Bitcoin, Ethereum, Litecoin, Ripple, etc.)
Type of
Virtual
Currency

Name of Virtual Currency
Email Address Used to Set Locations (Mobile Wallet, Virtual Currency
Wallet, Exchange, or Digital up with the Virtual
Online, External Hardware Amount and Value
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
by Insurance
Transportation
Gas/Parking/Insurance/Bus

Clothing/Personal Care Items
Total Monthly Living Expenses $

Real Estate (Include home, vacant land, cabin, etc.)
Address

County Where the
Property is located

Mortgage
Balance

Current
Value

Minimum Monthly
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.)
Year/Make

Model

Financed By

Balance Due

Minimum Monthly
Payment

Payoff Date

Total Motor Vehicles Minimum Monthly Payment $

Other Obligations (Include home equity, personal loans, amounts owed to IRS, etc.)
Type of Obligation

Current
Balance

Payoff Date

Minimum Monthly
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,
commissions, 1099, etc.)
Spouse’s Gross Monthly Pay
(wages, commissions, 1099, etc.)
Alimony/Child Support Paid to You
Rent Paid to You

Social Security/Retirement
Profit from Business
Other (unemployment, disability, etc.)
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 $
Payment frequency (circle one): Monthly

Date of first payment
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