Form         Indiana Department of Revenue 
                 FS-H         Claim for Hardship
              State Form 53302
                 (R2 / 6-15)

                              Financial Statement for Claim for Hardship
Please refer to pages 5 and 6 of this document to determine your eligibility and the requirements for this program. Your failure to 
follow all instructions provided and submit all required documentation will result in 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                                           Home Telephone

Cell Phone                                               Cell Phone

Date of Birth                                            Date of Birth

Email                                                    Email
                                  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

Telephone                                                Telephone
                              Bank Account(s) Information
                            Please include all checking, savings, credit union accounts, Certificates of Deposit, 
                              and safety deposit boxes held by you, your spouse, and dependents.
      Type of Account         Financial Institution Name        Account Number                              Present Balance

                                                         Page 1

Schedule 1                                               Monthly Household Income

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 Household Expenses

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 2

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                      Total Balance Due Monthly Payment

Schedule 4                                    Loan Information
                                   List all loans that are currently outstanding

Name of Financial Institution                       Monthly Payment             Total Balance Due

Schedule 5                                    Motor Vehicle Information

Year                               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 3

                                            Support Assistance (if applicable)
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 is currently residing with me and pays no 
monthly living expenses. 

___________________________________                ___________________________________           _________________
Printed Name                                      Signature                                      Date

                                                 Additional Information

                                                 Payment Plan Information
List your requested payment plan arrangements that you can presently make.                       

Down Payment: $  ____________________________                    Monthly Payment: $ __________________________

Before submitting your application, please review the following final checklist:
□ Completed the Form FS-H in its entirety.
□ Included a Letter of Circumstance.
□ Attached all of the required supporting documentation including proof of income and expenses.
 
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              Date

                                                  Page 4

                             Indiana Department of Revenue
                                  Claim for Hardship

Taxpayers with financial hardships that are unable to pay within the time limits set through the normal 
collection process may apply for a Claim for Hardship. The Taxpayer Advocate is authorized to 
review these cases and make every attempt to collect the tax, while meeting the special needs of the 
taxpayer. Submitting a Claim for Hardship does not ensure that the Indiana Department of Revenue 
will accept it.

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. After your Claim for Hardship is accepted, the department 
periodically reviews your case and you will be required to update all information previously submitted 
to this office.

Note: You must file all future tax returns timely 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 a Claim for Hardship?
•    Taxpayers who are facing financial difficulties
•    Taxpayers with terminal and/or critical illness/disability within the immediate family
•    Taxpayers with personal devastation resulting from a natural disaster or an uncontrollable 
     economic event

What the Claim for Hardship cannot do for you.
•    Cancel or discharge your outstanding liabilities with no payment
•    Leave your liabilities on hold indefinitely
•  Settle for a lesser amount
•    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 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
•    Establish a payment plan with the taxpayer’s special needs in mind, allowing additional time for 
     payment of the taxes due

Note: Your Claim for Hardship will be rejected if you do not submit all the required forms and 
supporting documentation with your application. Provide copies as documents will not be 
returned.

                                                Page 5

              Instructions for Submitting a Claim for Hardship

The following is required to submit a Claim for Hardship:
•    Complete the Claim for Hardship, Form FS-H, in its entirety.
•  Submit documented supporting evidence for all income, expenses, and accounts listed on 
     Form FS-H for the most recent month. If you fail to submit documented evidence with Form 
     FS-H, your application will be automatically rejected. Accepted documents include:
     ○  Income - Copies of paystubs, earnings statements, Social Security Administration 
          benefit letters, pension statements, bank statements reflecting direct deposits, food 
          stamp eligibility, etc.
     ○  Expense - Copies of monthly mortgage or lease statements, utility statements, credit 
          card or loan billings, medical bills, auto, home, or medical insurance billings, etc.
     ○  Accounts - Copies of all statements for bank, retirement, and investment accounts.
•  Submit a Letter of Circumstance explaining in detail what prevented you from paying the 
     taxes when they were due and what is currently preventing you from entering into a normal 
     collection payment plan agreement with the department.
•  Include a medical statement from your physician detailing the diagnosis and prognosis of you 
     and/or your family member’s medical condition(s), if applicable.
•  Include a Bankruptcy Discharge or Dismissal Notice, if applicable.
•    If you are requesting a payment plan agreement, you must also request a specific down 
     payment and monthly payment amount.
•    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 Financial Statement, for FS-H.

Note: The only expense items that the bank statements (debits) can be used for as supporting 
documentation are food and transportation (gas), and they must be identified and clearly marked 
on the statement. With the exception of food and transportation (gas), copies of actual billing 
statements must be provided.

If you have any questions, you can contact us 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

                                        Page 6