Form C58b - Business Information Statement
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4C58B
Business Information 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. This information may be used for collection purposes.
General information
Name of business
Federal ID number
Minnesota ID number
Business address
Type of organization (check one box)
Sole proprietor
C corporation
City, state and zip code
S corporation
Other (specify)
Partnership
Type of business
Business telephone number
Name and title of person submitting information
List all owners, general partners, or officers
Attach additional sheets if necessary.
Name (last name, first, MI)
Title
Effective dates
Home address (street, city, state, zip code)
Home telephone
Social Security no.
Name (last name, first, MI)
Title
Effective dates
Home address (street, city, state, zip code)
Home telephone
Social Security no.
Name (last name, first, MI)
Title
Effective dates
Home address (street, city, state, zip code)
Home telephone
Social Security no.
Licenses Provide the requested information for each license that is issued to the business, partner,
officer or owner by the State of Minnesota or any other unit of government to conduct a profession,
occupation, trade or business. Fill in the exact title of the license as it appears on the form or certificate
issued by the state or political subdivision. Attach additional sheets if necessary.
Issued to
License title
Issuing authority
Renewal date
Minnesota Department of Revenue, PO Box 64651, St. Paul MN 55164-0651
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651-556-3003 (Twin Cities) 1-800-657-3909 elsewhere in MN
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