Form                    Indiana Department of Revenue
      FS-H                            Hardship Financial Statement
      State Form 53302
      (R3 / 5-16)

                                              Contact Information

Name                                                 Spouse’s Name

Social Security Number                               Spouse’s Social Security Number

Phone                                                Spouse’s Phone

Date of Birth                                        Spouse’s Date of Birth

Email

Street Address   

City                                                 State                          ZIP Code

                                             Miscellaneous Information
Monthly Payment Requested  $                                    per month
Reason for hardship (medical, unemployed, devastating uncontrollable event).
Failure to attach supporting documentation/hardship reason will result in application being denied.

Federal Adjusted Gross Income on Most Recent Tax Return Filed            $

Number of Dependents Claimed on Return

Type of Bank Account    □ Savings □ Checking □ Other Balance of All Accounts:       $

                                              Circumstances
Explain in detail the type of hardship you are claiming; what prevented you from paying the taxes when they were due; and what 
currently prevents you from entering into a normal collection payment plan agreement. Attach additional sheets if needed.

                                      Support Assistance (if applicable)

If another individual is providing support assistance to you, that individual must list the extent of support they are providing (rent, grocer-
ies, etc.) and sign and date this form. Attach additional sheet if needed.

______________________________________________        ____________________________    ________________________
Support Provided                                     Signature                       Date

                                   Monthly Household Income (attach verification)

Your Net Pay/Commissions ................................................................................................................................ $ ___________________
Spouse’s Net Pay/Commissions ........................................................................................................................ $ ___________________
Rents Paid to You ............................................................................................................................................... $ ___________________ 
Pensions ............................................................................................................................................................. $ ___________________
Social Security Benefits/Disability ...................................................................................................................... $ ___________________
Profit from Business (Schedule C or K-1)........................................................................................................... $ ___________________
Alimony/Child Support ........................................................................................................................................ $ ___________________
Welfare/Food Stamp Assistance ........................................................................................................................ $ ___________________
Other Income (list source) .................................................................................................................................. $ ___________________
Total Monthly Income ....................................................................................................................................... $ ___________________

                                   Monthly Household Expenses (attach verification)

Rent/Mortgage .................................................................................................................................................... $ ___________________
Alimony/Child Support ........................................................................................................................................ $ ___________________
Groceries ............................................................................................................................................................ $ ___________________
Utilities ................................................................................................................................................................ $ ___________________
Transportation (gas, bus fare, etc.) .................................................................................................................... $ ___________________
Medical Expenses Not Paid by Insurance.......................................................................................................... $ ___________________
Insurance Cost:
   Automobile ....................................................................................................... $ ________________
   Health/Hospitalization Not Deducted from Pay............................................... $ ________________
   Life ................................................................................................................... $ ________________
   Homeowner’s/Rental Not Included in Mortgage ............................................. $ ________________
Total Cost Insurance ........................................................................................................................................... $ ___________________
Total Cost of Monthly Loan/Credit Card Payments............................................................................................. $ ___________________
   Loan/Credit Card Information (attach additional sheet if needed)
   Name of Financial Institution        Balance                    Monthly Payment
    _______________________             $ ____________________     $ ____________________
    _______________________             $ ____________________     $ ____________________
    _______________________             $ ____________________     $ ____________________
    _______________________             $ ____________________     $ ____________________
Total Monthly Expense ..................................................................................................................................... $ ___________________

                                                        Agreement

1. All returns must be on file and remain current. New liabilities could result in the cancellation of this agreement.
2.  All payments must be made timely. Defaulted payment plans will be cancelled, all holds will be released, and normal collection 
   efforts will resume. If payment plan is defaulted, department reserves the right to refuse future payment plans.
3. Failure to provide complete application, verification of all income and expenses, and any documentation supporting hard-
   ship claim will result in application being rejected.

Under penalties of perjury, I declare that all 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.
__________________________________________________                  ____________________________
Signature                                                          Date
__________________________________________________                  ____________________________
Signature                                                          Date

                                                 Hardship Program

Taxpayers with certain  hardships who are unable to pay within the time limits set through the normal collection process 
may apply for the Hardship Program. The Taxpayer Advocate is authorized to review these cases and make every at-
tempt to collect the tax, while meeting the special needs of the taxpayer. Submitting a request for the Hardship Program 
by completing the Hardship Financial Statement does not guarantee the Indiana Department of Revenue will accept your 
request.

Collection activities will continue during the review process. This could result in additional interest, fees, damages, and/or 
costs accruing. In addition, the department keeps any proceeds from a levy served prior to your hardship’s acceptance. 
Once your case is accepted, the ultimate goal is to establish a reasonable collection payment plan. This may require the 
department to periodically review your case and require you to update all information previously submitted to this office. 
You may be required to submit additional verification of income or expenses as needed.

Note: You must file all future tax returns and pay all future tax due timely. If you are issued a new tax liability or fail to file a 
timely return, the following will occur:
•     Your hardship payment plan agreement will be cancelled.
•     Your case will be closed.
•     Normal collection activities will resume.

Who may qualify for the Hardship Program
•     Taxpayers who have an immediate family member with a terminal and/or critical illness/disability
•     Taxpayers with personal devastation resulting from a natural disaster or uncontrollable event
•     Taxpayers who experience recent unemployment

What the Hardship Program cannot do for you
•     Cancel or discharge your outstanding liabilities with no payment or settle for a lesser amount
•     Leave your liabilities on hold indefinitely
•     Reinstate a revoked Registered Retail Merchant Certificate
•     Release a professional license, permit, or tax lien 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 Hardship Program can do for you
•     Establish a payment plan with your special needs in mind, allowing additional time for payment of the taxes due.
•     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

Note: Your application for the Hardship Program will be rejected if you do not submit all required forms and sup-
porting documentation with your Hardship Financial Statement. Please provide copies of documents; they will 
not be returned. 

          Instructions for Submitting an Application for the Hardship Program

The following is required in order to be considered from the Hardship Program:

• Complete the Hardship Financial Statement, Form FS-H, in its entirety.

• Submit documented supporting evidence for all income and expenses for the most recent two (2) months. 
  If you fail to submit the documented evidence with Form FS-H, your application will be rejected automatically. 
  Accepted documents include: copies of paystubs, earnings statements, Social Security Administration benefit 
  letters, pension statements, bank statements reflecting direct deposits, food stamp eligibility, loan statements, and 
  monthly bill statements. 

• Include documentation of Accounts. Copies of current statements for bank, retirement, and investment accounts 
  must be provided. 

• Include a medical statement from your physician detailing the diagnosis and prognosis of you and/or your family 
  member’s medical condition(s), if you are claiming a medical hardship. 

• Include a Bankruptcy Discharge or Dismissal Notice, if applicable. 

• If unemployed, please provide verification such as: separation letter, notice of business closure, registration with 
  the Indiana Department of Workforce Development, etc. 

• If you are requesting a payment plan agreement, you also must request a specific down payment and monthly 
  payment amount. Otherwise, a reasonable payment plan may be established based upon your application and 
  the necessary documented income and expenses.  

• If you are an out-of-state resident, include a copy of the most recently filed tax return for your home state or a 
  copy of your federal return if your home state return is not applicable.  

• If you are a corporation, include a copy of the most current filed federal return. Each owner/officer must provide 
  a completed Hardship Financial Statement with all required documentation.

If you have any questions, please contact the Taxpayer Advocate Office at (317) 232-4692 or taxadvocate@dor.in.gov. 
Allow 15 to 20 working days for processing.

                    Please mail your completed form and required documents to:
                                           Office of the Taxpayer Advocate
                                           Indiana Department of Revenue
                                            P.O. Box 6155
                                           Indianapolis, IN 46206-6155