Fillable Compromise Applicaon Before we will consider accepng less (Minnesota Department of Revenue)

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Compromise Applicaon Before we will consider accepng less (Minnesota Department of Revenue)

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Compromise Quesonnaire (see next page)
Non-refundable deposit
Make check payable to the Commissioner of Revenue. The
deposit will be included in the compromise amount if the
compromise is accepted. If your compromise request is
rejected, the $250 deposit will be applied to your account.
Loan applicaons and credit denials from at least two nan-
cial instuons
If you are unable to borrow the full amount of the debt,
provide statements from two nancial instuons indicang
the maximum amount they are willing to lend you.
Completed nancial statement (Form C58C)
Vericaon of income
Aach income vericaon (two most current pay stubs).
Vericaon of expenses
Aach copies of billing statements for the last two months
(mortgage, ulies, vehicles, insurance, court ordered pay-
ments, child care, other).
Bank informaon
Aach bank statements for savings and checking accounts
for the last three months.
Current lease or rental agreements
Aach all lease agreements, including property where you
are the lessor or lessee.
Investments
Aach copies of your most current statements (stocks,
bonds, mutual funds, IRAs, government securies, money
market funds, etc.).
Medical documentaon
Aach physician’s leers or other documents to show any
medical condion that should be considered and documen-
taon of medical expenses/prescripons not covered by
insurance.
Power of Aorney
Aach a power of aorney form (REV184) if this oer is
submied by a designated representave.
Real property informaon
Aach your most current property tax statements and
homeowners insurance policy (personal residence, vacaon
or second home, investment property, land, etc.).
Before we will consider accepng less than the full amount due, you must send the informaon requested below.
Your documentaon will be reviewed and veried. A Revenue Collecon Ocer may need to contact you to discuss the informaon
you submied. You will be noed in wring when a decision is made. Allow at least 90 days for a response.
Note: If you are seeking a compromise for a jointly led debt, either:
1. Both joint lers seek the compromise together. Both complete the nancial statement C58C, and the applicaon, and we use the
assets and income from both lers when determining the ability to pay. OR
2. The ler seeking the compromise must rst request a Separaon of Liability. If the liability is separated, the compromise you seek
will be for only those debts remaining in your name, and we will connue collecon eorts for the debts of the other joint ler.
Compromise Applicaon
Send all the required informaon and a $250 deposit to the address below. Keep a copy of all the informaon you provide us for your
records.
Minnesota Revenue
PO Box 64447-CMP
St. Paul, MN 55164-0447
(Rev. 12/17)
1. What is the maximum amount you can pay
for a lump-sum selement of your debt? $
Where will you obtain the funds?
2. Have you sold, transferred, or gied any
real estate during the past two years? Yes No
If yes, list property address, include the property idencaon
numbers, and aach documentaon.
3. Do you plan to buy, sell or renance real
estate in the next three years? Yes No
If yes, explain:
4. What caused your large tax liability? (Example: cashing of 401k or
stocks, claiming the wrong number of exempons, etc.)
Do you foresee having problems
meeng future tax obligaons? Yes No
If no, what has changed or been corrected?
5. If you are currently unemployed, what are your long-term job
prospects?
Do you have any health issues that prevent you from working? Explain
and aach the most current documentaon.
Compromise Quesonnaire
6. If business taxes are owed, what is
the status of your business? Open Closed
If closed, what date did it close?
Minnesota Tax Idencaon Number
7. Is anyone holding assets on your behalf
(e.g., trust fund, property)? Yes No
If yes, idenfy type of assets and value:
Relaonship to asset holder:
8. Is a foreclosure pending on any real estate
you own or have an interest in? Yes No
If yes, explain:
9. Is there a likelihood that you will receive assets
or income from an estate in probate? Yes No
If yes, from whom?
Relaonship:
10. Do you ancipate any increase in household
income in the next two years? Yes No
If yes, explain:
11. Why do you believe it is in the State’s best interest to sele your
account for less than the full amount due?
Your name: Your Social Security number:
The following informaon will be used to evaluate your ability to pay and to determine if a compromise is in the best interest of the State of Minnesota. This
informaon may be used for collecon purposes. You are not legally required to provide the informaon requested; however, if no informaon is provided
or if the informaon is insucient to make a determinaon, your request will be denied. (If you need more room to answer any of the quesons, please use
the back of this quesonnaire.)
your signature date dayme phone
spouse’s signature date dayme phone
Secon 1—General Informaon
Your Name Spouse’s Name
Your Social Security Number Your Date of Birth Spouse’s Social Security Number Spouse’s Date of Birth
Your Address Own Rent Spouse’s Address (if dierent) Own Rent
City County State ZIP Code City County State ZIP Code
Home Phone Number Work Phone Number Spouse’s Home Phone Number Spouse’s Work Phone Number
C58C
Individual Financial Statement for Oer in Compromise
This informaon may be used for collecon purposes. We are allowed to require Social Security numbers under 42 USC 405 (c) (2) (C) (i). You are not
legally required to provide the informaon requested. However, if you do not provide enough informaon your request may be denied. Include all
household income and expenses even if only one person is liable for the tax.
You Full-Time Part-Time Spouse Full-Time Part-Time
Employee Sole Proprietor Partner Ocer Employee Sole Proprietor Partner Ocer
Your Employer or Business Name Occupaon Spouse’s Employer or Business Name Occupaon
Address Address
City State Zip Code City State ZIP Code
Length of employment (years/months) Length of employment (years/months)
Paid Weekly Bi-weekly Semi-monthly Monthly Paid Weekly Bi-weekly Semi-monthly Monthly
Highest level of educaon aained? Highest level of educaon aained?
Professional License Renewal Dates Spouse’s Professional Licenses Renewal Dates
Year of Last Filed Income Tax Return Federal State Year of Last Filed Income Tax Return Federal State
Allowances Claimed on W4 Allowances Claimed on W4
Personal Representave/Tax Preparer (Aach Power of Aorney Form REV184) Personal Representave/Tax Preparer (Aach Power of Aorney Form REV184)
Address Address
City State ZIP Code Phone Number City State ZIP Code Phone Number
(Rev. 12/17)
Bank and Credit Union Accounts (checking, savings, CDs, etc.) Aach copies of savings and checking account bank statements for the last three months.
Name of Instuon Address Type of Account Account Number Balance
Total bank assets
$
Secon 2—Asset Informaon
Other Assets Current Value
Cash surrender value of life insurance
Judgments or selements receivable
Notes receivable
Other (specify)
Motor Vehicles (cars, trucks, RVs, campers, motorcycles, boats, trailers, snowmobiles, ATVs, etc.) Aach addional sheets if necessary.
Make Model Year Amount Owed Payo Date Minimum Equity in Vehicle
Monthly Payment
Real estate (personal residence, vacaon or second home, investment property, land, etc.). Aach most current property tax statements and home owners insurance
policy.
Current Amount
Descripon Address City State Market Value Owed Equity in Property
Investments (stocks, bonds, mutual funds, rerement accounts, government securies, money market funds, etc.) Aach copies of most current statements.
Type of Investment Issuer Quanty Current Value
Secon 2—Asset Informaon, Connued
Total Investments
Total Real Estate Equity
Total Vehicle Equity
$
$
$
Total Other Assets
$
Credit Cards (Visa , MasterCard, American Express, Discover, etc.)
Card Name Credit Limit Current Balance Minimum Monthly Payment
Household informaon (you are not legally required to provide the informaon requested; however, if no informaon is provided or the informaon is insucient
to make a determinaon, your request may be denied). List all people living in household (other than spouse informaon from Secon 1).
Name Relaonship to you Age Income Contributed
(partner, roommate, parent, etc.)
Secon 3—Liability Informaon (not included in assets previously listed). Aach copies of most current billing statements.
Total Credit Payments
If you owe past due federal tax, is this debt currently under levy by IRS? Yes No If yes, what amount?
Do you have an oer in compromise pending with the IRS? Yes No If yes, what amount?
$
Total Household Income (add to “Household income” on pg. 4) $
Total Number in Household
Bank Line of Credit
Federal Tax Debts
Total Liability Payments
$
Other Liabilies
Personal Loans, Judgments or Notes Payable
Type of Liability Current Balance Minimum Monthly Payment
I declare that the informaon in this statement is true and correct to the best of my knowledge and belief. I authorize the Department of Revenue
to verify any informaon on this form.
Your signature Date Spouse’s signature Date
Monthly Income. Aach income vericaon (two most current pay
stubs).
Source You Spouse
Salary, wages, ps
Overme, bonuses,
commissions
Self-employment income
(net prot from Schedule C
or Schedule C-EZ divided by 12)
Pensions, disability and
Social Security
Dividend, interest
and investment income
Rental income
Estate, trust and
royalty income
Workers compensaon
and unemployment
Alimony and child
support
Other (specify)
The informaon you provide on this form is condenal. It can only be given to the Internal Revenue Service, other states, Minnesota
municipalies, the Minnesota Aorney General in the administraon of tax laws, the Minnesota Department of Human Services if there is any
evidence you have deserted your children or are delinquent in child support payments, or another person who must list some or all of your income
or expenses on his or her tax return.
Monthly living expenses (if self employed, do not include expenses already
claimed on Schedule C). *Aach copies of billing statements for the last three
months.
Source Amount
Groceries
Clothing and personal care
*Mortgage or rent payments
*Ulites
Electric Phone
Water/Sewer Garbage
Gas/oil Cable
Total ulies
*Vehicle payments
Transportaon (gas/oil, license, bus fare, etc.)
Miles driven to/from work per week
*Medical expenses and prescripons
not paid by insurance
*Insurance
Life Health
Auto Home
Total insurance
Income taxes (federal/state/SS/FICA)
Esmated quarterly tax payments
(divide by three to get monthly amount)
Property tax
*Court ordered payment (child support, alimony, etc.)
*Child care
*Other (specify)
Secon 4—Income and Expense Analysis
Monthly income
$
Combined income
Household income (from pg. 3)
Total income
$
Total expenses
Net disposable monthly income (subtract “Total expenses” from “Total income”) .................................
$
Total credit payments (from pg. 3)
Monthly expenses
Total liability payments (from pg. 3)
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Compromise Applicaon Before we will consider accepng less (Minnesota Department of Revenue)

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Completed 20 November 2020

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