OMB Approved No. 2900-0165
Respondent Burden: 1 hour
FINANCIAL STATUS REPORT
1. SOCIAL SECURITY NO. 2. FILE NO.
(Type or print all entries. If more space is needed for any item, continue
under Section VII, Additional Data, Item 36 or attach separate sheet)
3. SPECIFY WHY YOU ARE COMPLETING THIS FORM
(Waiver, Compromise, Payment Plan or Other)
PRIVACY ACT INFORMATION: The information you furnish on this form is almost always used to determine if you are eligible for waiver of a debt, for the
acceptance of a compromise offer or for a payment plan. Disclosure is voluntary. However, if the information is not furnished, your eligibility for waiver, compromise
or a payment plan may be affected. The responses you submit are confidential and protected from unauthorized disclosure by 38 U.S.C. 5701. The information may be
disclosed outside the Department of Veterans Affairs (VA) only when authorized by the Privacy Act of 1974, as amended. The routine uses for which VA may disclose
the information can be found in VA systems of records, including 58VA21/22, Compensation, Pension, Education and Rehabilitation Records-VA, and 88VA244,
Accounts Receivable Records-VA. VA systems of records and alterations to the systems are published in the Federal Register. Any information provided by you,
including your Social Security Number, may be used in computer matching programs conducted in connection with any proceeding for the collection of an amount owed
by virtue of your participation in any benefit program administered by VA.
RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB
Control Number. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have comments regarding
this burden estimate or any other aspect of this collection of information, call 1-800-827-0648 for mailing information on where to send your comments.
SECTION I - PERSONAL DATA
4. FIRST-MIDDLE-LAST NAME OF PERSON 5. ADDRESS (Number and street or rural route, City or P.O. Box, State, and ZIP Code)
6. TELEPHONE NO. (Include Area Code) 7. DATE OF BIRTH (MM-DD-YYYY)
8. MARITAL STATUS
MARRIED NOT MARRIED
9. NAME OF SPOUSE 10. AGE(S) OF OTHER DEPENDENTS
COMPLETE RECORD OF EMPLOYMENT FOR YOURSELF AND SPOUSE DURING PAST 2 YEARS
11. YOUR EMPLOYMENT EXPERIENCE
KIND OF JOB
DATES (MM-YYYY)
FROM TO
PRESENT TIME
NAME AND ADDRESS OF EMPLOYER
12. YOUR SPOUSE'S EMPLOYMENT
PRESENT TIME
SECTION II - INCOME
AVERAGE MONTHLY INCOME
13. MONTHLY GROSS SALARY
(Before payroll deductions)
SELF
$
SPOUSE
$
14. PAYROLL DEDUCTIONS
A. FEDERAL, STATE AND
LOCAL INCOME TAXES
B. RETIREMENT
C. SOCIAL SECURITY
D. OTHER (Specify)
E. TOTAL DEDUCTIONS
(Items 14A through 14D)
15. NET TAKE HOME PAY
(Subtract Item 14E from Item 13)
16. VA BENEFITS, SOCIAL
SECURITY, OR OTHER INCOME
(Specify source)
17. TOTAL MONTHLY NET
INCOME (Item 15 plus Item 16)
$ $
SECTION III - EXPENSES
AVERAGE MONTHLY EXPENSES
18. RENT OR MORTGAGE PAYMENT
$
AMOUNT
19. FOOD
20. UTILITIES AND HEAT
21. OTHER LIVING EXPENSES
22. MONTHLY PAYMENTS ON INSTALLMENT
CONTRACTS AND OTHER DEBTS (Include amount
from Section VI, Line 34I - Column E.)
23. TOTAL MONTHLY EXPENSES
$
SECTION IV - DISCRETIONARY INCOME
24A. NET MONTHLY INCOME LESS EXPENSES (Item 17 less Item 23)
$
24B. AMOUNT YOU CAN PAY ON A MONTHLY BASIS TOWARD YOUR DEBT
$
VA FORM
JUN 2009 (RS)
5655
