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Minnesota Free Printable Form C58P, Personal Financial Statement for 2024 Minnesota Personal Financial Statement

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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
Extracted from PDF file 2023-minnesota-form-c58p.pdf, last modified March 2022

More about the Minnesota Form C58P Individual Income Tax TY 2023

Information provided on this form will be used to evaluate the debtor's ability to pay the taxes owed and determine acceptable payment terms if a payment agreement is found appropriate. Form C58P requires you to list multiple forms of income, such as wages, interest, or alimony .

We last updated the Personal Financial Statement in February 2024, so this is the latest version of Form C58P, fully updated for tax year 2023. You can download or print current or past-year PDFs of Form C58P directly from TaxFormFinder. You can print other Minnesota tax forms here.

Other Minnesota Individual Income Tax Forms:

TaxFormFinder has an additional 95 Minnesota income tax forms that you may need, plus all federal income tax forms.

Form Code Form Name
Form M1PR Homestead Credit Refund (for Homeowners) and Renters Property Tax Refund
Form M1 Instructions Minnesota Individual Income Tax Instructions (Form M1)
Form M1 Individual Income Tax Return
Form M1PR Instructions Homestead Credit Refund and Renter’s Property Tax Refund Instruction Booklet
Form M1M Income Additions and Subtractions (onscreen version)

Download all MN tax forms View all 96 Minnesota Income Tax Forms


Form Sources:

Minnesota usually releases forms for the current tax year between January and April. We last updated Minnesota Form C58P from the Department of Revenue in February 2024.

Show Sources >

About the Individual Income Tax

The IRS and most states collect a personal income tax, which is paid throughout the year via tax withholding or estimated income tax payments.

Most taxpayers are required to file a yearly income tax return in April to both the Internal Revenue Service and their state's revenue department, which will result in either a tax refund of excess withheld income or a tax payment if the withholding does not cover the taxpayer's entire liability. Every taxpayer's situation is different - please consult a CPA or licensed tax preparer to ensure that you are filing the correct tax forms!

Historical Past-Year Versions of Minnesota Form C58P

We have a total of three past-year versions of Form C58P in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2023 Form C58P

Form C58P, Personal Financial Statement

2022 Form C58P

Form C58P, Personal Financial Statement

2021 Form C58P

Team bL0107 Suspension Application (take 2)


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