Personal Financial Statement Form - Minnesota Department Of Revenue
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2C58P
Personal Financial Statement
This information will be used to evaluate your ability to pay what you owe, determine if a payment agreement is
appropriate, and what payment terms are acceptable. We are allowed to require Social Security numbers under
42 USC 405 (c)(2)(C)(i). You are not legally required to provide the information requested; however, if no
information is provided or the information is insufficient to make a determination, your request will be denied. You
may attach a statement with additional details to explain your situation and the circumstances that you believe
prevent you from paying your liability in full at this time. This information may be used for collection purposes.
Your full name
Spouse's full name
Your Social Security number
Your birth date
Spouse's Social Security number
Spouse's birth date
Your address
Spouse's address (if different)
City
State
Zip code
City
State
Zip code
Home phone number
Work phone number
Spouse's home phone number
Spouse's work phone number
Employment
Spouse
Full-time
Part-time
Full-time
Part-time
Your employer or business name
Occupation
Spouse's employer or business name
Occupation
Address
Address
City
State
Zip code
City
State
Zip code
Professional licenses held by you
Renewal dates
Professional licenses held by spouse
Renewal dates
Real estate
(home, land, cabin, etc.) Attach addtitional sheets if necessary, include copies of your property tax statements.
Mortgage
Current
Minimum
Address
City
State
County
balance
value
payment
Bank accounts
(credit unions, money market, stocks, bonds, 401[k]s, IRAs, etc.) Attach additional sheets if necessary.
Type of account
(checking, savings, other-specify)
Name and address of institution
Account number
Name on account
Balance/value
Motor vehicles
(cars, boats, RVs, motorcycles, snowmobiles, ATVs, etc.) Attach additional sheets if necessary.
Minimum
Year/make
Model
Financed by
Balance due
Payoff date
monthly payment
Minnesota Department of Revenue, PO Box 64564, St. Paul MN 55164-0564, 651-556-3003 (Twin Cities) 1-800-657-3909 elsewhere in MN, Rev. 12/11
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