DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0270
Financial Statement of Debtor
(Submitted for Government Action on Claims Due the United States)
(NOTE: Use additional sheets where space on this form is insufficient or continue on reverse side of pages.)
Authority for the solicitation of the requested information is one or more of the following: 42 CFR 405.376; 4 CFR 101, et.seq.;
31 U.S.C. 951, et seq.
The principal purpose for gathering this information is to evaluate your capacity to pay the Government’s claim against you.
Disclosure of the information is voluntary. If the requested information is not furnished, the Government will pursue
immediate and full payment of its claim against you.
1. Name
(debtor) 2. Birth Date (mo., day, yr.)
3. Home Address 4. Phone No.
5. Name of Spouse (give address if different from yours) 6. Date of Birth (mo., day, yr.)
Debtor Employment Data
7. Occupation 8. How Long in Present Employment?
9. Present Employer’s Name Address Phone No.
10. Other Employment—Within Last 3 Years
Employer’s Name Address Phone No.
Employment
Dates
11. Present Monthly Income
Salary or Wages $ Commissions $ Other (state source) $ Total $
Spouse’s Employment Data
12. Occupation 13. How Long in Present Employment?
14. Spouse’s Present Employer’s Name Address Phone No.
15. Other Employment—Within Last 3 Years
Employer’s Name Address Phone No.
Employment
Dates
16. Present Monthly Income
Salary or Wages $ Commissions $ Other (state source) $ Total $
Dependents
17. Total
Number
Relationship Age Relationship Age Relationship Age
18. Total Monthly Income of
Dependents (except spouse)
$
Form CMS-379 (07/07) EF 07/2007 Page 1 of 4
Financial Data
19. For What Period Did You Last 20. Where Filed 21. Amount of Gross Income
File a Federal Income Tax Return Reported
22. Fixed Monthly Expenses
Rent Food Utilities Interest
Debt Repayments (Including installments) Other (specify)
Total Fixed Monthly Charges
23. Loans Payable
Owed To Purpose & Date of Loan
Original
Amount
Present
Balance
24. Assets and Liabilities
Assets
(Fair market value)
Cash $
Checking Accounts (show location)
Savings Accounts (show location)
Motor Vehicles
Year Make/License No.
Debts Owed to You (give name of debtor)
Judgments Owed to You
Stocks, Bonds and Other Securities (itemize)
Household Furniture and Goods
Items Used In Trade or Business
Other Personal Property (itemize)
Real Estate
Total Assets $
Liabilities
Bills Owed (grocery, doctor, lawyer, etc.) $
Installment Debt (car, furniture, clothing, etc.)
Taxes Owed
Income
Other (itemize)
Loans Payable (to banks, finance company, etc.)
Judgments You Owe
Real Estate Mortgages
Other Debts (itemize)
Total Liabilities $
Form CMS-379 (07/07) EF 07/2007 Page 2 of 4
25. Real Estate Owned
Address How Owned (jointly,
individually, etc.)
Date
Acquired
Cost Unpaid Amount
of Mortgage
26. Real Estate Being Purchased Under Contract
Address Name of Seller
Contract Price Principal Amount Still Owing Next Cash Payment Due (date) Amount (of next payment due)
27. Life Insurance Policies
Company Face Amount Cash Surrender Value Outstanding Loans
28. All Real and Personal Property Owned by Spouse and Dependents Valued in Excess of $200 (List each item separately)
29. All Transfers of Property Including Cash (by loan, gift, sale, etc.) That You Have Made Within the Last 3 Years (items of $300 or over)
Date Amount Property Transferred To Whom
30. Are you a party in any lawsuit now pending? Yes, give details below No
31. Are you a trustee, executor, or administrator? Yes, give details below No
32. Is anyone holding any moneys on your behalf? Yes, give details below No
Form CMS-379 (07/07) EF 07/2007 Page 3 of 4
33. Is there any likelihood you will receive an inheritance? Yes, from whom? No
34. Do you receive, or under any circumstances, expect to receive benefits, from any established trust, from a claim for compensation or
damages, or from a contingent or future interest in property of any kind?
Yes, explain below No
With knowledge of the penalties for false statements provided by 18 United States Code 1001 ($10,000 fine and/or 5 years imprisonment) and
with knowledge that this financial statement is submitted by me to affect action by the Department of Health and Human Services, I certify
that I believe the above statement is true and that it is a complete statement of all my income and assets, real and personal, whether held in
my name or by any other.
Date Signature
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0270. The time required to complete this information collection is estimated to
average 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Form CMS-379 (07/07) EF 07/2007 Page 4 of 4
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