Form

5668

Garnishment Hardship Application*17000000001*
17000000001

Frequently Asked Questions

Form Instructions

What is a hardship modification?
A hardship modification allows qualifying taxpayers toreduce a current wage, bank, or brokerage garnishment if
it creates a hardship. A hardship exists if the garnishment
prevents the taxpayer from meeting necessary living
expenses.

Personal Information- Print or type your name, social security number,address, best day time contact telephone number, ande-mail address in the spaces provided.
- Print or type the name of all other persons in the house
hold including those claimed as a dependent, their age,and their relationship to you in the spaces provided.
- Select “Yes” or “No” if the person can be claimed as adependent and if they contribute to the household.
- Print or type the name, address, telephone number, andfax number of Tax Representative. Also fill out andattach the Missouri Power of Attorney (Form 2827).

What can a hardship do for me?
Upon approval, a hardship could lower the percentage ofwages garnished per pay period or allow a release of thegarnishment in exchange for an installment agreement.
What can a hardship not do for me?
A hardship cannot delay or cancel existing collection
actions, avoid or abate existing tax liabilities, or release alien.
What are some reasons a hardship may be denied?
- The taxpayer fails to make full financial disclosure, including
household income.
- The taxpayer submits false or misleading information.
- The taxpayer has not fully filed all tax types.
- The taxpayer has repeated noncompliance or attempts toavoid paying tax obligations.
Is professional assistance required to submit a hardship?
Professional assistance is not required, but taxpayers arewelcome to seek tax assistance from a tax professional ifthey choose.
How does the hardship process work?
When you submit a completed application with allnecessary supporting documentation, the Department will
determine whether you are able to meet all necessary
living expenses if the garnishment continues without
modification. If you cannot, the Department will notify youof your options.
What happens when a decision has been made?
If the hardship is approved, a modification of garnishment
will be mailed to the taxpayer and the garnishee; and will
be filed with the Circuit Court Clerk. If the hardship isdenied, the Department will contact you to inform you why
the hardship is being denied, as well as, mail a letter to thetaxpayer’s address on file.

Employment- Print or type the name of employer, telephone number,
length of employment, address, occupation, pay
frequency, and average net income in the spaces
provided.
- Attach additional pages if needed to list all employers for
all person’s in the household including those who can beclaimed as a dependent and contribute to the household.
Property- Print or type the year, make, model, purchase date, loanbalance and monthly payment for all automobiles, boats,
ATV’s, motorcycles, recreational vehicles, airplanes,machinery, etc.
- Print or type the type of dwelling, address, purchasedate, loan balance, and monthly payment for all real
property owned.
Financial- Print or type the name of the financial institution,
address, account number, and balance for all bankaccounts.
- Include IRA’s, other retirement plans, certificates ofdeposit, etc. Attach all pages of the most recent threemonths bank statements for all accounts of each personin the household. Attach additional pages as needed. If
you owe more than $50,000, six months of bankstatements are required.
- Print or type the amount for all applicable other sourcesof income in the spaces provided. Add up all othersources of income and fill in the space provided.
Signature- Please sign and date the line applicable to you, after
reading and understanding the Certification.
- Using the checklist provided, ensure all required,applicable, documentation is available to be sent in withthe application that is completed and signed.

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Department Use OnlyForm

5668(MM/DD/YY)

Garnishment Hardship Application*17359010001*
17359010001

Social Security Number-

Spouse’s Social Security Number--

Taxpayer Name

Spouse’s Name

Current Street Address

CityStateZIP CodeE-mail AddressCountyTelephone Number

Payment Plan Agreement-

Secondary Telephone Number

Percentage Reduction

Personal Information

Provide information for all other persons in the household including those claimed as a dependent. Attach additional pages as needed.

NameAgeRelationship

Claimed as a Dependent

Contributes toon your Form 1040?

Household Income?

Yes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

NoYes

No

Name of Tax Representative (CPA, Attorney, etc.) Attach Form 2827

Street Address

CityTelephone Number

Fax Number

State

ZIP Code

Provide information for all other persons in the household including those claimed as a dependent. Attach additional pages as needed.

Employment

Name of Employer (Taxpayer)

Street Address

Occupation

Telephone NumberCity

Pay FrequencyState

Average Net Income. 00

ZIP Code

How Long Employed
Years

MonthsName of Employer (Spouse)

Employment (Continued)

Street Address

Occupation

Telephone Number

CityState

Pay Frequency

Average Net Income

ZIP Code

How Long Employed

. 00

Years

MonthsAdditional Employment
Name of Employer (Taxpayer or Spouse)

Street Address

Occupation

Telephone Number

City

StatePay Frequency

Average Net Income

ZIP Code

How Long Employed

. 00

Years

Months

Personal Property: Include automobiles, boats, ATV’s, motorcycles, recreational vehicles, airplanes, machinery, etc, not used in your business.
Attach additional pages as needed and supporting documentation of payoff.

PropertyYear

Make and Model

Purchase Date (MM/DD/YYYY)

Loan Balance.

.

.

.

.

.

Real Property: For each property, include copies supporting documentation of loan balance including monthly payment. Attach additional pages
as needed.
Type

Street Address

Purchase Date (MM/DD/YYYY)

City

Loan BalanceStreet Address

Purchase Date (MM/DD/YYYY)

State

ZIP CodeState

ZIP CodeMonthly Payment.
Type.

City

Loan Balance

Monthly Payment.
Financial - Bank Accounts

Monthly Payment.

Bank Accounts: Include IRA’s, other retirement plans, certificates of deposit, etc. Attach all pages of the most recent three months bank statements
for all accounts of each person in the household, Attach additional pages as needed. If you owe more than $50,000, six months bank statements
are required. Provide information for all persons in the household or claimed as a dependent.
City of Institution
Account Number
Balance as of Date (MM/DD) Balance
Name of Institution.
.
.

*17359020001*
17359020001

Financial - Other Sources of Income

TaxpayerSpouseSelf-Employment Income  . . . . . . . . . . . . . . 

.

.

Pensions, Disability, and Social Security . . .

.

.

Dividends and Interest . . . . . . . . . . . . . . . . . 

.

.

Gift or Loan Proceeds . . . . . . . . . . . . . . . . . 

.

.

Rental Income . . . . . . . . . . . . . . . . . . . . . . . 

.

.

Estate, Trust and Royalty Income . . . . . . . . 

.

.

Workers’ Comp and Unemployment . . . . . . 

.

.

Alimony and Child Support  . . . . . . . . . . . . . 

.

.

Other (Specify)  . . . . . . . . . . . . . . . . . . . . . . 

.

.

Additional Income Total . . . . . . . . . . . . . . . . 

.

.

Additional Income Grand Total.

Signature

Under penalties perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities, and other information is true,correct, and complete.
Taxpayer’s Signature

Printed Name

Date (MM/DD/YYYY)

Spouse’s Signature

Printed Name

Date (MM/DD/YYYY)

Power of Attorney Signature

Printed Name

Date (MM/DD/YYYY)

Hardship Application form filled out completely and signed.
Attach Missouri Power of Attorney Form 2827 if you want to authorize someone other than you to be able to discuss this application with theHardship Application Checklist

Department.
Three consecutive months of the most current bank statements for all members of the home.
Include IRA’s, other retirement plans, certificates of deposit, etc. Attach all pages of the most recent three months bank statements for all
accounts of each person in the household. Attach additional pages as needed. If you owe more than $50,000, six months bank statements arerequired.
Three consecutive months of the most current monthly bills for all members in the home.
Statements do need to show current amount due, previous balance due, payments made, and cycle date.
This includes, but is not limited to, utility bills, car payment, insurance, telephone, credit card, and IRS payment plans.
If you lease or rent and do not get a monthly statement, please include a copy of the lease or rent agreement.
Three consecutive months of the most current wage statements for all members in the home.
Must be copy of pay stub, showing pay period and dates, gross income, deductions, and net pay.

Mail to:Taxation Division
P.O. Box 1646
Jefferson City, MO 65105-1646

Phone: (573) 522-6276
Fax: (573) 522-2404
E-mail: collections@dor.mo.gov

Form 5668 (Revised 08-2017)*17359030001*17359030001