Fillable Form Instructions: *17000000001* Frequently Asked Questions (Missouri)

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Form Instructions: *17000000001* Frequently Asked Questions (Missouri)

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What is a hardship modication?
A hardship modication allows qualifying taxpayers to
reduce a current wage, bank, or brokerage garnishment if
What can a hardship do for me?
Upon approval, a hardship could lower the percentage of
wages garnished per pay period or allow a release of the
What can a hardship not do for me?
A hardship cannot delay or cancel existing collection
What are some reasons a hardship may be denied?
- The taxpayer fails to make full nancial disclosure, including
household income.
Is professional assistance required to submit a hardship?
Professional assistance is not required, but taxpayers are
How does the hardship process work?
When you submit a completed application with all
necessary supporting documentation, the Department will
determine whether you are able to meet all necessary
What happens when a decision has been made?
If the hardship is approved, a modication of garnishment
will be mailed to the taxpayer and the garnishee; and will
be led with the Circuit Court Clerk. If the hardship is
Frequently Asked Questions
- The taxpayer submits false or misleading information.
- The taxpayer has not fully led all tax types.
it creates a hardship. A hardship exists if the garnishment
prevents the taxpayer from meeting necessary living
garnishment in exchange for an installment agreement.
actions, avoid or abate existing tax liabilities, or release a
- The taxpayer has repeated noncompliance or attempts to
avoid paying tax obligations.
welcome to seek tax assistance from a tax professional if
living expenses if the garnishment continues without
denied, the Department will contact you to inform you why
the hardship is being denied, as well as, mail a letter to the
Form Instructions
Personal Information
- Print or type your name, social security number,
address, best day time contact telephone number, and
e-mail address in the spaces provided.
- Print or type the name of all other persons in the house
hold including those claimed as a dependent, their age,
and their relationship to you in the spaces provided.
Employment
- Print or type the name of employer, telephone number,
length of employment, address, occupation, pay
frequency, and average net income in the spaces
provided.
Property
- Print or type the year, make, model, purchase date, loan
balance and monthly payment for all automobiles, boats,
ATV’s, motorcycles, recreational vehicles, airplanes,
Financial
- Print or type the name of the nancial institution,
address, account number, and balance for all bank
accounts.
- Include IRA’s, other retirement plans, certicates of
deposit, etc. Attach all pages of the most recent three
Signature
- Please sign and date the line applicable to you, after
reading and understanding the Certication.
- Using the checklist provided, ensure all required,
modication. If you cannot, the Department will notify you
- Select “Yes” or “No” if the person can be claimed as a
dependent and if they contribute to the household.
- Print or type the name, address, telephone number, and
fax number of Tax Representative. Also ll out and
- Attach additional pages if needed to list all employers for
all person’s in the household including those who can be
machinery, etc.
- Print or type the type of dwelling, address, purchase
months bank statements for all accounts of each person
in the household. Attach additional pages as needed. If
you owe more than $50,000, six months of bank
statements are required.
- Print or type the amount for all applicable other sources
applicable, documentation is available to be sent in with
the application that is completed and signed.
they choose.
attach the Missouri Power of Attorney (Form 2827).
date, loan balance, and monthly payment for all real
expenses.
lien.
of your options.
taxpayer’s address on le.
claimed as a dependent and contribute to the household.
property owned.
of income in the spaces provided. Add up all other
sources of income and ll in the space provided.
Missouri Department of Revenue
Garnishment Hardship Application
Form
5668
*17000000001*
17000000001
Yes
Missouri Department of Revenue
Garnishment Hardship Application
Form
5668
Current Street Address City State ZIP Code
E-mail Address
Personal Information
County
Telephone Number
Secondary Telephone Number
Provide information for all other persons in the household including those claimed as a dependent. Attach additional pages as needed.
Name of Tax Representative (CPA, Attorney, etc.) Attach Form 2827
Street Address City State ZIP Code
Telephone Number
Fax Number
Employment
Provide information for all other persons in the household including those claimed as a dependent. Attach additional pages as needed.
Name
Claimed as a Dependent Contributes to
Name of Employer (Taxpayer) Telephone Number
Occupation Pay Frequency Average Net Income How Long Employed
Years
00
.
RelationshipAge on your Form 1040? Household Income?
NoYes No
Months
Yes NoYes No
Yes NoYes No
Yes NoYes No
Street Address City State ZIP Code
Payment Plan Agreement Percentage Reduction
*17359010001*
17359010001
Department Use Only
(MM/DD/YY)
Social Security Number Spouse’s Social Security Number
Taxpayer Name Spouse’s Name
- - - -
Reset Form
Print Form
Employment (Continued)
Name of Employer (Spouse) Telephone Number
Occupation Pay Frequency Average Net Income How Long Employed
Years
Additional Employment
Name of Employer (Taxpayer or Spouse) Telephone Number
Occupation Pay Frequency Average Net Income How Long Employed
Property
Personal Property: Include automobiles, boats, ATV’s, motorcycles, recreational vehicles, airplanes, machinery, etc, not used in your business.
Attach additional pages as needed and supporting documentation of payoff.
Year
Real Property: For each property, include copies supporting documentation of loan balance including monthly payment. Attach additional pages
as needed.
Type
Purchase Date (MM/DD/YYYY)
Financial - Bank Accounts
Bank Accounts: Include IRA’s, other retirement plans, certicates of deposit, etc. Attach all pages of the most recent three months bank statements
for all accounts of each person in the household, Attach additional pages as needed. If you owe more than $50,000, six months bank statements
are required. Provide information for all persons in the household or claimed as a dependent.
Name of Institution
. .
. .
Monthly PaymentMake and Model Purchase Date (MM/DD/YYYY) Loan Balance
City of Institution Account Number Balance as of Date (MM/DD)
Loan Balance Monthly Payment
Type
Purchase Date (MM/DD/YYYY) Loan Balance Monthly Payment
00
.
00
.
Months
Years Months
. .
. .
. .
Street Address City State ZIP Code
Street Address City State ZIP Code
Street Address City State ZIP Code
Street Address City State ZIP Code
Balance
.
.
.
*17359020001*
17359020001
Financial - Other Sources of Income
Self-Employment Income ...............
Pensions, Disability, and Social Security . . .
Dividends and Interest
.................
Gift or Loan Proceeds..................
Rental Income .......................
Estate, Trust and Royalty Income ........
Workers’ Comp and Unemployment.......
Alimony and Child Support..............
Other (Specify) .......................
Additional Income Total ................
Signature
Under penalties perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities, and other information is true,
correct, and complete.
Taxpayer’s Signature Printed Name Date (MM/DD/YYYY)
Spouse’s Signature Printed Name Date (MM/DD/YYYY)
Power of Attorney Signature Printed Name Date (MM/DD/YYYY)
Mail to: Taxation Division Phone: (573) 522-6276
P.O. Box 1646 Fax: (573) 522-2404
Jefferson City, MO 65105-1646 E-mail: collections@dor.mo.gov
Form 5668 (Revised 08-2017)
Additional Income Grand Total
Taxpayer Spouse
. .
. .
. .
. .
. .
. .
. .
. .
. .
. . .
Hardship Application form lled out completely and signed.
Attach Missouri Power of Attorney Form 2827 if you want to authorize someone other than you to be able to discuss this application with the
Department.
Three consecutive months of the most current bank statements for all members of the home.
Include IRA’s, other retirement plans, certicates of deposit, etc. Attach all pages of the most recent three months bank statements for all
accounts of each person in the household. Attach additional pages as needed. If you owe more than $50,000, six months bank statements are
Three consecutive months of the most current monthly bills for all members in the home.
Statements do need to show current amount due, previous balance due, payments made, and cycle date.
This includes, but is not limited to, utility bills, car payment, insurance, telephone, credit card, and IRS payment plans.
If you lease or rent and do not get a monthly statement, please include a copy of the lease or rent agreement.
Three consecutive months of the most current wage statements for all members in the home.
Must be copy of pay stub, showing pay period and dates, gross income, deductions, and net pay.
Hardship Application Checklist
required.
*17359030001*
17359030001
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Form Instructions: *17000000001* Frequently Asked Questions (Missouri)

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Completed 7 December 2021

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