INDIPAY Financial Data Request Forms

The INDIPAY financial data request form requires the individual to provide financial information to support its claim of inability to pay the civil penalty. Both an English and Spanish version are provided.

• 2024 INDIPAY Financial Data Request Form in English (pdf) (526.85 KB)
  This is the english version of Indipay.
• 2024 INDIPAY Financial Data Request Form in Spanish (pdf) (717.23 KB)
  This is the spanish version of the Indipay form.