Form C58p Personal Financial Statement - Minnesota Department Of Revenue
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4C58P
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
Spouse’s Social Security #
Spouse’s Birth Date
Your Social Security #
Your Birth Date
Spouse’s Street Address (if different than yours)
Your Street Address
City
State
ZIP Code
City
State
ZIP Code
Spouse’s Home Phone
Spouse’s Work Phone
Home Phone
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 Part-time
Employer or Business Name
Occupation
Employer or Business Name
Occupation
Street Address
Street Address
City
State
ZIP Code
City
State
ZIP Code
Bank Accounts (
credit unions, money market, stocks, bonds, 401(k)s, IRAs, etc.)
Type of Account
Name of Institution
(checking, savings,
Account Number
Name on Account
Balance/Value
other – specify)
Total Bank Accounts Balance/Value
$
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Parent category: Financial