Personal Financial Statement Form - Minnesota Department Of Revenue Page 2
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1
2Personal Financal Statement
Credit cards
(Visa, MasterCard, American Express, Discover, etc.)
Card name
Credit limit
Current balance
Minimum mo. payment
Other obligations
(home equity, personal loans, amounts owed to IRS, etc.)
Type of obligation
Payoff date
Current balance
Minimum mo. payment
Monthly income
Attach the two most recent pay stubs for each person.
Your gross pay (wages, commissions, 1099, etc) . . .
Soc. Security/retirement. . . . . . . . . . . .
Spouse's gross pay (wages, commissions, 1099, etc)
Profit from business. . . . . . . . . . . . . . .
Alimony/child support paid to you . . . . . . . . . . . . . . . .
Other (unemployment, disability, etc)
Rent(s) paid to you. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total monthly income
$
Monthly expenses
Attach additional sheets if necessary.
Number in household
Ages
Taxes withheld
Housing and utilities
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 . . . . . . . . . . . .
Cable . . . . . . . . . . . . . . .
Medical expenses not
Groceries . . . . . . . . . . . . . . . . .
paid by insurance . . . . . . .
Clothing/personal care items
Transportation
Gas/parking/insurance . . .
Total credit cards . . . . . . . . . . .
Bus . . . . . . . . . . . . . . . . . . .
Total other obligations . . . . . .
Total motor vehicles . . . . . . . .
Total monthly expenses
$
Payment terms you are requesting
Proposed payment amount:
$______________ to be paid
monthly
starting
(date)
biweekly (every other week)
weekly
If your payment terms are accepted, the payment amount you proposed will be withdrawn from your bank account on the starting date
you selected by Electronic Funds Transfer and a payment agreement will be sent to you. Penalty and interest will accrue, as provided
by law, until the balance is paid in full. Payment agreements are subject to a nonrefundable $50 fee.
Bank name
Account #
Routing #
Type of account
checking
savings
Name on account
Account holder phone #
Will funding for this transaction be transmitted to or received from a financial
yes
no
agency located outside the territorial jurisdiction of the United States?
Bank information must be completed or we will not be able to complete your agreement as requested.
I declare that the information in this statement is true and correct to the best of my knowledge and belief. I understand that material
misrepresentation on this form may be grounds for denial of an agreement. I authorize the Department of Revenue to verify any
information on this form.
Your signature
Date
Spouse's signature
Date
The information you provide on this form is confidential.
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