Form Mdes - 1852 - Personal Financial Statement
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2MINNESOTA DEPARTMENT OF EMPLOYMENT AND ECONOMIC DEVELOPMENT
PERSONAL FINANCIAL STATEMENT
ACCOUNT #__________________________
ABOUT THIS FORM: The purpose of this form is to evaluate your ability to pay the amounts that you owe. Based upon the
information you provide, a determination will be made as to whether an installment payment arrangement or a compromise
settlement is appropriate and what payment terms the Department will accept. The information on this form might be used for
collection purposes in the event an installment payment contract or settlement agreement cannot be reached. You are not
legally required to provide the information requested on this form. However, if you fail to do so your request for an installment
payment contract or settlement will be denied.
APPLICANT
SPOUSE
(Name)
(Date of Birth)
(Name)
(Date of Birth)
(Social Security Number)
(Marital Status)
(Social Security Number)
(Marital Status)
(Address)
(Address)
(City, State, Zip Code)
(County)
(City, State, Zip Code)
(County)
)
)
(Home Phone)
(Business Phone
(Home Phone)
(Business Phone
(Age and Relationship of Dependents)
(Age and Relationship of Dependents)
(Employer’s Name)
(How Many Years?)
(Employer’s Name)
(How Many Years?)
(Employer’s Address)
(Employer’s Address)
(City, State, Zip Code)
(City, State, Zip Code)
PERSONAL FINANCIAL INFORMATION
RESIDENCE: Rent _______
Own _______
If Own, Cost $_____________________
Market Value $________________________
Mortgage or Contract for Deed Balance $____________________ Property Type: Torrens or Abstract ___________________
: No / Yes
If yes, _________________________________________________________________
OTHER REAL ESTATE
(Address, City, State, County)
Cost $________________ Market Value $_______________ Mortgage or Contract for Deed Balance $__________________
: List the names and addresses of all financial institutions in which you have any type of financial
FINANCIAL INSTITUTIONS
account. Financial institutions include Banks, Savings & Loans, Credit Unions, Brokerage Accounts, Mutual Fund Accounts
or other checking accounts. Some types of financial accounts are checking, saving, IRA’s, certificates of deposit, KEOGH
accounts, and annuities. Also provide the account number and current balance. If more than two, list the additional accounts on
a separate piece of paper.
Name & Address of Financial Institution
Type of Account
Account #
Current Balance
MDES – 1852 (Revised 09/03)
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