Indiana Department of Revenue Claim for Hardship What is required to apply for a Claim for Hardship? • Complete a Financial Statement, form FS-H. • Must be current with all tax filings. • Any Bankruptcy filings must have already been discharged or dismissed. Who may qualify for a Claim for Hardship? • Taxpayers who are facing financial difficulties due to: ○ Terminal and/or critical medical illness within the immediate family. ○ Personal devastation resulting from a natural disaster or an uncontrollable event. What the Claim for Hardship can not do for you.... • Cancel your outstanding liabilities with no payment. • Leave your liabilities on hold indefinitely. • Settle for a lesser amount. • Release a professional license, permit, or tax lien on any type of property until the amount due is paid in full. • Intervene when a legal action has been filed, such as wage garnishment, bank account levy, collection suit, or court ordered appearance. What the Claim for Hardship can do for you? • Place a temporary hold on your account for a specified time period, with the intention of establishing a payment plan at the end of that time period. • Establishing a payment plan with the taxpayer’s special needs in mind, allowing additional time for repayment of the taxes due. Attention: Your application can be rejected for the following reasons: • • • • Advanced collection proceedings: If a legal action has been filed (i.e. levy of wages and/or bank account, collection suit, or appearance in court). Past and/or Present income levels. Information listed on the Financial Statement: Failure to provide verification of all income, accounts, and expenses must be submitted for the current month and previous three (3) months Failure to submit the following required documentation: ○ A Letter of Circumstances answering in detail what prevented you from paying the taxes when they were due and what is currently preventing you from entering into a payment plan with the Collection Division of the Department. ○ A medical statement from your physician detailing the diagnosis and prognosis of your and/ or a family members medical condition(s), if applicable. ○ Incomplete, illegible, and/or unsigned Financial Statement. ○ Bankruptcy Discharge or Dismissal notice, if applicable. ○ If you are a current or recently out-of-state resident, copies of the state tax return filed for the last three (3) years that was filed. ○ Copies of the federal tax return filed for the last three (3) years, including all pertinent schedules. Page  American LegalNet, Inc. www.FormsWorkflow.com  ○ If a corporation:  The last three (3) years of corporate returns or financial statements.  Proof of borrowing power.  Each owner/officer must provide a completed Financial Statement, form FS-H Any required tax filings not on file with the Department, both individual and business. Claim for Hardship instructions:  All pertinent information must be completed on the Financial Statement  If a payment plan is being requested, a specific down payment and monthly payment amount must be requested.  Please note: the down payment must be received with the Claim for Hardship.  If a hardship hold is being requested, a specific amount of time must be requested (i.e. six months) prior to the start of your payment plan. Please note: If accepted into the Claim for Hardship program, your case may be reviewed periodically and you will be required to update all information previously submitted to this office. You must file all future returns on time and any amount due must be paid timely. Failure to do so will result with your payment plan being cancelled, your case closed, and normal collection pursuit resuming. You can contact us at: Office of the Taxpayer Advocate Indiana Department of Revenue P.O. Box 6155 Indianapolis, Indiana 46206-6155 (317) 232-4692 www.in.gov/dor/3883.htm Page  American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Revenue FS-H Claim for Hardship SF# 53302 (R/5-07) Financial Statement for Claim for Hardship Please refer to pages 1 and 2 of this document to determine your eligibility and the requirements for this program. Your failure to follow all instructions provided and submitting all required documentation will result with your application being rejected. You will be notified within 15 to 20 working days, or less, if you have been accepted into or rejected from the Claim for Hardship program. Personal Information Name: Spouse’s Name: Social Security Number: Spouse’s Social Security Number: Address: Address: City, State, Zip: City, State, Zip: Home Telephone Number: ( Cell Phone: ( ) Home Telephone Number: ( ) Cell Phone: ( Date of Birth: ) ) Date of Birth: Dependents Please list the name, age and relationship of all dependents who live with you. Name Age Relationship Employment Information Your Employer’s Name: Spouse’s Employer’s Name: Years Employed: Years Employed: Address: Address: City, State, Zip: City, State,Zip: Phone Number: ( ) Phone Number: ( ) Bank Account(s) Information Please include all checking, savings, credit union accounts, Certificates of Deposit, and list safety deposit boxes held by you, your spouse and dependents. Type of Account Financial Institution Name Account Number Page  Present Balance American LegalNet, Inc. www.FormsWorkflow.com Schedule 1 Monthly Income Information Your net pay...............................................................................................................................$ _____________ Your spouse’s net pay................................................................................................................$ _____________ Rents paid to you (list property rent is being derived from)......................................................$ _____________ Pensions.....................................................................................................................................$ _____________ Social Security Benefits.............................................................................................................$ _____________ Social Security Disability..........................................................................................................$ _____________ Profit from your business (must attach federal Schecule C, E, F or any other pertinent schedules) . ..$ _____________ Commissions..............................................................................................................................$ _____________ Alimony/Child support received................................................................................................$ _____________ Welfare/Food stamp assistance.................................................................................................$ _____________ Other income (please list source) . ............................................................................................$ _____________ Total Monthly Income ............................................................................................................$ _____________ Schedule 2 Monthly Expenses Information Rent ...........................................................................................................................................$ _____________ Mortgage ...................................................................................................................................$ _____________ Alimony/Child support paid .....................................................................................................$ _____________ Groceries ...................................................................................................................................$ _____________ Electricity . ................................................................................................................................$ _____________ Heat (oil, gas, etc.) ....................................................................................................................$ _____________ Water/Sewer ..............................................................................................................................$ _____________ Telephone ..................................................................................................................................$ _____________ Transportation (gasoline, bus fare, etc.) . ..................................................................................$ _____________ Medical Expenses (physician’s bills, medication not paid by insurance) ................................$ _____________ Insurance Cost Automobile ..................................................................................... $________________ Health/Hospitalization .................................................................... $________________ Life . ................................................................................................ $________________ Homeowner’s/Renter’s ................................................................... $________________ Total cost of insurance (auto, health, life, home, rental, etc.)....................................................$ _____________ Total cost of credit card payments (list card information on Schedule 3).................................$ _____________ Total loan payments (list loan information on schedule 4)........................................................$ _____________ Other expenses (please itemize and explain below) . ............................................................$ _____________ Total Monthly Expenses .........................................................................................................$ _____________ Other Expenses Itemized Monthly Expenses and Explanations (attach additional sheets as needed) Page  American LegalNet, Inc. www.FormsWorkflow.com Schedule 3 Credit Card Information List all credit card, lines of credit, and check overdraft protection held by you, your spouse, and/or your dependents (attach additonal sheet as needed) Name Credit Limit Schedule 4 Expiration Date Loan Information List all loans that are currently outstanding Name of Financial Institution Amount of Payment Balance Due Schedule 5 Year Balance Due Motor Vehicle Information Make/Model Financed Through Current Value Schedule 6 Real Estate Information Address Financed Through Current Value Other assets List other items that you, your spouse, and/or your dependents own or are currently buying (i.e. stocks, bonds, boats, furniture, jewelry, mechanics tools, RV, etc… Page  American LegalNet, Inc. www.FormsWorkflow.com If you are currently living with another individual, family or friend, and are paying no monthly expenses, that individual must read and understand the statement below and then sign and date this form. Under penalties of perjury, I declare that the named individual(s) on this Financial Statement are currently residing with me and pay no monthly living expenses. Printed Name Signature Date Additional Information Payment Plan Information List below your requested payment plan arrangements that you can presently make. Down Payment: $ Monthly Payment: $ Please explain how you determined these figures: Under penalties of perjury, I declare that this statement of assets and liabilities and all other information included in this document or attached thereto are true and correct to the best of my knowledge and belief. I authorize the Indiana Department of Revenue to verify any and all facts included in this document. Your Signature Date Spouse’s Signature Page  Date American LegalNet, Inc. www.FormsWorkflow.com