DR 6596 (04/07/23)
                                                         COLORADO DEPARTMENT OF REVENUE – COLLECTIONS
                                                         P.O. Box 17087
*136596==19999*                                          Denver, CO 80217-0087
                                                         Page 1 of 2
                               Statement of Economic Hardship
The Department of Revenue uses this form to determine if the tax levy or standard installment agreement amount prevents 
you from meeting basic, reasonable living expenses. Be sure to write clearly and do not leave any area blank.
If additional space is needed, please attach a separate sheet that includes your name, social security number and clearly 
classify the additional information according to the areas below.
                                                                              Account Number, if known                   Date (MM/DD/YY)

Taxpayer Information
Taxpayer Name                                                                 SSN                                        DOB

Spouse Name                                                                   SSN                                        DOB

Address                                                                       City                                       State ZIP

Daytime Phone                                                                 Email

Age and relationship of people living with you (dependents only):

Employer Information
Current Employer - Taxpayer                                                                                              Phone

Employer Address                                                              City                                       State ZIP

Length of Employment                                                          Pay Cycle (monthly, biweekly, weekly)      Net Pay (after taxes)

Current Employer - Spouse                                                                                                Phone

Employer Address                                                              City                                       State ZIP

Length of Employment                                                          Pay Cycle (monthly, biweekly, weekly)      Net Pay (after taxes)

Non-Wage Household Income - list monthly amounts for the entire household

Profit from business           $                                         Unemployment Income                             $

Commissions                    $                                         Interest/Dividends                              $

Pension/Social Security Income $                                         Net Rental Income                               $

Alimony/Child Support Income   $                                         Other Income                                    $

TOTAL INCOME - enter the sum of all household income                                                                     $
Accounts -  include checking, online/mobile (PayPal, etc.), savings, loans, CD, credit union, etc. 
        Name of Institution                                      Address                           Account Number             Current Balance

                                                                                                                         $

                                                                                                                         $
Securities - include stocks, bonds, annuities, mutual funds, IRA, money market funds, whole life insurance policies, etc.
                 Type                                            Issuer                     Quantity/Denomination              Current Value

                                                                                                                         $

                                                                                                                         $
                               Please complete reverse side of form

                                                    DR 6596 (04/07/23)
                                                    COLORADO DEPARTMENT OF REVENUE – COLLECTIONS
                                                    P.O. Box 17087
*136596==29999*                                     Denver, CO 80217-0087
                                                    Page 2 of 2
Taxpayer Name                                                                              Account Number, if known

Real Estate – include home, vacation, timeshares, rental properties, etc.
Description/Location/County             Mortgage Company                                          Current Value         Balance Owed

Primary residence? Y /N                                                                                                $

Primary residence? Y /N                                                                                                $
Motor Vehicles – include cars, boats, recreation vehicles, etc.
Year/Make/Model/License Plate           Financing Company                                         Current Value         Balance Owed

                                                                                                                       $

                                                                                                                       $
                                      Monthly Necessary Living Expenses
Enter the monthly amount of your expenses.  For any expenses not paid monthly, convert as follows:
Quarterly bills: divide by 3
Weekly bills: multiply by 4.3
Biweekly bills: multiply by 2.17
Expenses should be reasonable for the size of your household.  Substantiation may be required for any expenses over a reasonable amount. The 
national standard will be considered for food, clothing, and other allowable items.

Rent or mortgage payment              $                                  Transportation (gas, parking, bus fare, etc.) $

Child support and/or alimony paid     $                                  Out-of-pocket medical                         $

Child/Dependent care                  $                                  Health insurance premiums                     $

Food and housekeeping supplies        $                                  Life insurance premiums                       $

Gas/Electric                          $                                  Automobile insurance                          $

Water/Sewer                           $                                  Homeowners or renters insurance               $

Telephone, cable, internet, cellphone $                                  Car loan payment                              $
Other Debt – include lender name and account numbers

                                                                                                                       $

                                                                                                                       $

                                                                                                                       $

TOTAL EXPENSES – enter the sum of all household expenses                                                               $
Additional information – describe any expected changes to your income, expenses or employment below.

Under penalty of perjury, I declare to the best of my knowledge and belief this statement of assets, liabilities and other information is true, correct and complete.
Spouse signature                                                         Taxpayer signature

                        This form can be mailed to the address listed above, attached to a secure message 
                                at Colorado.gov/RevenueOnline, or sent via fax to 303-866-2037.