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Get MN DoR C58P 2022-2024

C58P Personal Financial Statement 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. Personal Information Spouse s Full Name Your Full Name Your Social Security Spouse s Social Security Your Birth Date Spouse s Birth Date Spouse s Street Address if different than yours Your Street Address City State Home Phone ZIP Code Spouse s Home Phone Work Phone Spouse s Work Phone Total Number and Ages of People in Your Household Current Employment Information You circle one Full-time Part-time Your Spouse circle one Full-time Employer or Business Name Occupation Street Address Part-time Bank Accounts credit unions money market stocks bonds 401 k s IRAs etc* Name of Institution Type of Account checking savings other specify Account Number Name on Account Total Bank Accounts Balance/Value Balance/Value Real Estate home vacant land cabin etc* County Where the Property is located Address Mortgage Balance Current Value Total Real Estate Minimum Monthly Payment Minimum Monthly Payment Credit Cards Visa MasterCard American Express Discover etc* Card Name Credit Limit Total Credit Cards Minimum Monthly Payment Motor Vehicles cars boats RVs motorcycles snowmobiles ATVs etc* Year/Make Model Due Financed By Payoff Date Total Motor Vehicles Minimum Monthly Payment Minimum Monthly 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 Medical Expenses Not Paid by Transportation Gas/Parking/Insurance/Bus Groceries Clothing/Personal Care Items Total Monthly Living Expenses Other Obligations home equity personal loans amounts owed to IRS etc* Type of Obligation Payoff Date 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 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 s Paid to You Soc* 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 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 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 the payment amount you are proposing we will send you a letter explaining the terms of the payment agreement.

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