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
