Form C58b - Business Information Statement (Page 4 of 4) in pdf

Conditions

1. Copies of the most recent business financial statements (including but not limited to balance sheets and profit

and loss statements) should be submitted with this form.

Personal Financial Statement (C58P) forms must be submitted with this form for each owner, partner, or officer.

Attach a copy of all currently recorded UCC-1 financing statements on which the business is either a creditor or

debtor.

Each owner, partner, or officer must disclose their name, address, and the nature of any involvement or interest

in other businesses.

Payment terms you are requesting

I am requesting to pay the total liability plus accrued penalties and interest in the following manner:

Proposed payment amount:

$ _______________ to be paid

monthly

starting ________________

biweekly (every other week)

(date)

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If your payment terms are accepted, the payment amount you proposed will be withdrawn from your bank account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

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 I have provided in this statement is true and correct to the best of my knowledge and

belief. I understand 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. I understand and am aware that:

· the commissioner of revenue or delegated representative will evaluate the information I have provided and the

terms I have requested;

· the commissioner of revenue or a delegated representative shall have the sole authority to accept or reject my

terms;

· the information provided will be used to collect my liability if my terms are not accepted or if I default on

acceptable payment terms;

· I may be required to provide documentation to substantiate any information included on this form; and

· the completion and submission of this form does not constitute acceptance of my terms by the commissioner of

revenue.

Signature

Printed name

Title

Date

All information you provide on this form is confidential.

Stock No. 8000130

Rev. 11/11

Form C58b - Business Information Statement Page 4

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