Form 5655 Financial Status Report

OMB Approved No. 2900-0165
Respondent Burden: 1 hour

FINANCIAL STATUS REPORT
1. SOCIAL SECURITY NO.

2. FILE NO.

3. SPECIFY WHY YOU ARE COMPLETING THIS FORM
(Waiver, Compromise, Payment Plan or Other)

(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)
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

5. ADDRESS (Number and street or rural route, City or P.O. Box, State, and ZIP Code)

4. FIRST-MIDDLE-LAST NAME OF PERSON

6. TELEPHONE NO. (Include Area Code)

7. DATE OF BIRTH (MM-DD-YYYY)

8. MARITAL STATUS
MARRIED

9. NAME OF SPOUSE

NOT MARRIED

10. AGE(S) OF OTHER DEPENDENTS

COMPLETE RECORD OF EMPLOYMENT FOR YOURSELF AND SPOUSE DURING PAST 2 YEARS
DATES (MM-YYYY)
NAME AND ADDRESS OF EMPLOYER
KIND OF JOB
FROM

TO

11. YOUR EMPLOYMENT EXPERIENCE
PRESENT TIME

12. YOUR SPOUSE'S EMPLOYMENT
PRESENT TIME

SECTION II - INCOME

AVERAGE MONTHLY INCOME
13. MONTHLY GROSS SALARY
(Before payroll deductions)

SELF

$

SECTION III - EXPENSES

SPOUSE
$

14. PAYROLL DEDUCTIONS

AVERAGE MONTHLY EXPENSES
18. RENT OR MORTGAGE PAYMENT

AMOUNT

$

19. FOOD

A. FEDERAL, STATE AND
LOCAL INCOME TAXES

20. UTILITIES AND HEAT

B. RETIREMENT

21. OTHER LIVING EXPENSES

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)

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

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25. CASH IN BANK (Checking and savings accounts,
building and loan accounts, etc.)

SECTION V - ASSETS

29. U.S. SAVINGS BONDS
(Current Value)

$

$

26. CASH ON HAND

30. STOCKS AND OTHER BONDS
(Current Value)

27. AUTOMOBILES (Resale value)

31. REAL ESTATE OWNED
(Resale value)

MAKE

YEAR

MODEL

28. TRAILERS, BOATS, CAMPERS (Resale value)

32. OTHER ASSETS (Specify below)

$

$

33. TOTAL ASSETS

SECTION VI - INSTALLMENT CONTRACTS AND OTHER DEBTS
NOTE: Show below ALL debts which you are required to pay in regular monthly installments, such as a car, television, washing
machine, payments to dealers, banks, finance companies, repayment of money borrowed for any purpose, doctor bills, hospital bills,
etc. DO NOT INCLUDE LIVING EXPENSES.
DATE
AND PURPOSE
OF DEBT
(B)

NAME AND ADDRESS OF CREDITOR
(A)
34A.

ORIGINAL
AMOUNT OF
DEBT
(C)

UNPAID
BALANCE

AMOUNT DUE
MONTHLY

(D)

(E)

AMOUNT
PAST DUE
(If any)
(F)

$

$

$

$

$

$

$

$

34B.

34C.

34D.

34E.

34F.

34G.

34H.

34I. TOTAL

NOTE: If repayment of a debt is not on a monthly basis, write "0" in column E and describe arrangements to repay in Item 36.

SECTION VII - ADDITIONAL DATA

35A. HAVE YOU EVER BEEN ADJUDICATED BANKRUPT? IF SO AND VA OR A MORTGAGE COMPANY WAS INVOLVED, PLEASE SEND ALL PERTINENT
DOCUMENTATION

YES

NO (If "Yes," complete Items 35B through 35D)

35B. DATE DISCHARGED FROM BANKRUPTCY (MM-DD-YYYY) 35C. LOCATION OF COURT

35D. DOCKET NO. (If known)

36. USE THIS SPACE AND ADDITIONAL SHEETS, IF NECESSARY, TO SUPPLY ANY PERTINENT INFORMATION AND TO CONTINUE YOUR ANSWER TO
PREVIOUS ITEM NUMBER(S) TO WHICH YOUR COMMENTS APPLY

SECTION VIII - APPLICANT CERTIFICATIONS - REQUIRED
37A. YOUR SIGNATURE (Required )

37B. DATE SIGNED

38A. SIGNATURE OF SPOUSE (Required )

38B. DATE SIGNED

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,
knowing it to be false.
BACK OF VA FORM 5655, JUN 2009 (RS)

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