Forms Revision Chart for FEMA Form 127-0-1

Location (Revised form)	Current Text	Revised Text
Page 1	PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden….	PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden….
Page 1	PRIVACY ACT STATEMENT	PRIVACY ACT STATEMENT
Page 1	AUTHORITY: 5 U.S.C 301: The Federal Record Act, 44 U.S.C. 2101: The Homeland Security Act of 2001, Public Law 107‐296, 6 U.S.C.121; Public law 89‐508; Federal Claims Collections Act of 1966, 31.U.S.C. 3701; and Executive Order 9373. Solicitation of the Social Security Number (SSN) is authorized under the provisions 31 U.S.C 7701	AUTHORITY: 5 U.S.C 301: The Federal Record Act, 44 U.S.C. 2101: The Homeland Security Act of 2001, Public Law 107‐296, 6 U.S.C.121; Public law 89‐508; Federal Claims Collections Act of 1966, 31.U.S.C. 3701; and Executive Order 9373. Solicitation of the Social Security Number (SSN) is authorized under the provisions 31 U.S.C 7701
Page 1	PRINCIPAL PURPOSE(S): This information is to evaluate debtor's ability to pay the government's claim or judgement.	PRINCIPAL PURPOSE(S): This information is to evaluate debtor's ability to pay the government's claim or judgement.
Page 1	ROUTINE USE(S): In general, DHS/FEMA will only use this information as stated above. DHS/FEMA may share this information on a case‐by‐case basis as required by law or as necessary for a specific purpose, as described in the routine uses found in the Accounts Receivable System of Records Notice., DHS/ALL‐008 (October 17, 2008, 73 FR 61885). Pursuant to 31 U.S.C 3711, the Federal Emergency Management Agency (FEMA) is required to transfer delinquent debts over 180 days old to the Department of the Treasury (Treasury for collection. When the debt is submitted for collection, the debtor's name and SSN will be shared with Treasury with sources of payments that may be due the debtor. Treasury will reduce or withhold any of the debtor's eligible Federal payments by the amount of the debt. Treasury may also refer the debt to the Department of Justice, a private debt collection agency, and/or report debtor information to a consumer credit reporting agency	ROUTINE USE(S): In general, DHS/FEMA will only use this information as stated above. DHS/FEMA may share this information on a case‐by‐case basis as required by law or as necessary for a specific purpose, as described in the routine uses found in the Accounts Receivable System of Records Notice., DHS/ALL‐008 (October 17, 2008, 73 FR 61885). Pursuant to 31 U.S.C 3711, the Federal Emergency Management Agency (FEMA) is required to transfer delinquent debts over 180 days old to the Department of the Treasury (Treasury for collection. When the debt is submitted for collection, the debtor's name and SSN will be shared with Treasury with sources of payments that may be due the debtor. Treasury will reduce or withhold any of the debtor's eligible Federal payments by the amount of the debt. Treasury may also refer the debt to the Department of Justice, a private debt collection agency, and/or report debtor information to a consumer credit reporting agency
Page 1	DISCLOSURE: The disclosure of information on this form is voluntary. If the requested information on this form is voluntary. If the requested information is not furnished, FEMA has the right to such disclosure of the information by legal methods	DISCLOSURE: The disclosure of information on this form is voluntary. If the requested information on this form is voluntary. If the requested information is not furnished, FEMA has the right to such disclosure of the information by legal methods.
Page 1	WARNING	WARNING
Page 1	Title 18, Sec. 1001 U.S. Code: “Whoever knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious statements or representations, shall be fined not more than $10,000 or imprisoned not more than five years, or both.”	Title 18, Sec. 1001 U.S. Code: “Whoever knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious statements or representations, shall be fined not more than $10,000 or imprisoned not more than five years, or both.”
Page 1	I declare Under the penalties provided for by Title 18, Section 1001 of the U.S. Code that all Answers and Statements contained Herein Are to the best of my knowledge and belief, Ture, Correct and complete. _____________________________ ________________ Signature Date	I declare Under the penalties provided for by Title 18, Section 1001 of the U.S. Code that all Answers and Statements contained Herein Are to the best of my knowledge and belief, Ture, Correct and complete. _____________________________ ________________ Signature Date
Page 1	NAME OF DEBTOR/NAME OF SPOUSE
Page 1	DATE OF BIRTH/HOME PHONE/SOCIAL SECURITY
Page 1	COMPLETE ADDRESS (Including zip code and county)
Page 1	MARITAL STATUS/NUMBER OF CHILDREN (give age (s))/NUMBER OF DEPENDENTS
Page 1	NAME OF EMPLOYER
Page 1	ADDRESS
Page 1	POSITION (No. of years there) / Salary (Hr., Mo., Yr.)
Page 1	OTHER INCOME (Source)/ OTHER INCOME (Mo.)
Page 2		Instructions:
Page 2	CAR(S) OWNED (Make, Model & Year)/ AMT. OWED/ MO.PYMT	Complete all blocks. Write “N/A” in blocks that do not apply. Use additional sheets if necessary. Must provide with this financial statement: Copies of your last 2 paystubs. Entire last Federal tax return – All schedules required for filing or sign the statement below, stating that you are not required to file a tax return; and Last monthly bank statement for all monetary accounts. Non-FEMA Employees submit this form and supporting documentation to Fax: 800-827-8112 or Mail: National Processing Service Center. P.O. Box 10055, Hyattsville, MD 20782-8005 Current and Former FEMA Employees submit this form and supporting documentation to FAX
Page 1		Entire last Federal tax return – All schedules required for filing or sign the statement below, stating that you are not required to file a tax return; and Last monthly bank statement for all monetary accounts.
Page 1		Non-FEMA Employees submit this form and supporting documentation to Fax: 800-827-8112 or Mail: National Processing Service Center, P.O. Box 10055, Hyattsville, MD 20782-8055. Current and Former FEMA Employees submit this form and supporting documentation to Fax: 540-504-2288 or Mail: FEMA Finance Center, Accounts Receivable, P.O. Box 9001, Winchester, VA 22604. I, , certify that I am not required to file a tax return. Signature Date
Page 1
Page 1
Page 1		PERSONAL INFORMATION
Page 1	NAME OF SPOUSE	NAME OF SPOUSE/PARTNER
Page 1	Date of Birth Home Phone	DATE OF BIRTH SOCIAL SECURITY NUMBER DATE OF BIRTH SOCIAL SECURITY NUMBER
		MARITAL STATUS:
Page 1		COUNTY of PARISH
Page 1		BEST NUMBER AN DTIME TO REACH YOU: # TIME
Page 1	MARITAL STATUS, NUMBER OF CHILDREN(give age(s)), NUMBER OF DEPENDENTS (other than children)	NAMES OF DEPENDENTS (include only dpendent's that an be claimed on your tax return) ‐ explain any differences, AGE / RELATIONSHIP (child, parent, etc.) / Contributes to household income ‐ Circle one YES NO
Page 2	Name of Employer / Name of Employer	PRESENT EMPLOYER'S NAME *Attach last 2 pay stubs / PRESENT EMPLOYER'S NAME (SPOUSE/PARTNER) *Attach last 2 pay stubs
Page 2	Address, Position (No of Years there), Salary (Hr., Mo., Yr.)	POSITION HELD & NO. OF YEARS
Page 2	Other Income (Source), Other Income (Mo)	OTHER INCOME
Page 2		(Enter Monthly Gross Income)
Page 2		( Include information for yourself, spouse, partner, children, and anyone else who contributes to your household income.
Page 2		**Attach entire Schedule C and/or Schedule E from your Federal Tax Return / NAME / NAME / NAME / NAME
Page 2		Each of these types are listed on separate lines: **Self‐Employment, Commissions, Tips, Interest Income, Dividend Income, **Rental Income, **Business Income, Unemployment Compensation, Pensions, Annuities, Other Retirement, Alimony Received, Child Support, Other Income (list type), Other Income (list type), Other Income (list type), Other Income (list type) **Each income line has 4 columns to input for each individual contributing to household income
Page 3		BENEFITS
Page 3		(Enter Monthly Benefit Amount)

Page 1	HOUSING RENT BY MONTH OWN (Title in Name of) ________________
Page 1	MO. PYMT. OR RENT $ ____ YR.PUR ____ COST$ ____MKT VALUE $____ AMT MORTGAGE $____
Page 1	DO YOU OWN ANY OTHER REAL ESTATE? Address (include county) No Yes DO YOU OWN ANY STOCK OR BONDS
Page 1	AMT OWED$____ MKT VALUE$___ MO PYMT.$_____ NO YES (Value) $______
Page 2	CAR(S) OWNED (make, Model & Year)/AMT. OWED/ MO. PYMT	Instructions:
Page 2	__________________________/ $_______________/ $_________________ __________________________/ $_______________/ $_________________ NAME OF BANK(S) (include Address and account number)/ HOW DO YOU PROPOSE TO PAY YOUR DEBT TO THE UNITED STATES? CHECKING – AVG BALANCE $_________ / $________ per month beginning ___ 20, _____ SAVINGS – BALANCE $_________ / I WILL PAY: a Lump Sum of $ ___ on ___ 20,____	Complete all blocks. Write “N/A” in blocks that do not apply. Use additional sheets if necessary. Must provide with this financial statement: a.Copies of our last 2 paystubs b. Entire last Federal Tax return – All schedules required for filing or sign the statement below, stating that you are not required to file a tax return; and c. Last monthly bank statement for all monetary accounts. Non-FEMA Employees submit this for and supporting documentation to Fax:800-827-8112 or Mail: National Processing Service Center, P.O. Box 10055, Hyattsville, MD 20782-8005 Current and Former FEMA Employees submit this form and supporting documentation to Fax: 540-504-2288 or Mail: FEMA Finance Center, Accounts Receivable, P.O. Box 9001, Winchester, VA 22604
Page 2	NAME OF CREDITORS (Use reverse side if more space is needed)/ AMT OWED / MONHTLY PAYMENT/AMOUNT PAST DUE 1._________________/______________/_________________/_________________ 2._________________/______________/_________________/_________________ 3._________________/______________/_________________/_________________	I, _______________________, certify that I am not required to file a tax return. _______________________________________ ________________________ Signature Date
Page 2		PERSONAL INFORMATION
Page 2		NAME OF DEBTOR/NAME OF SPOUSE/PARTNER
Page 2		DATE OF BIRTH/SOCIAL SECURITY NUMBER/DATE OF BIRTH/SOCIAL SECURITY NUMBER
Page 2		MARITAL STATUS / BEST NUMBER AND TIME TO REACH YOU Phone Number Time
Page 2		COMPLETE ADDRESS (Including zip code)/ ADDRESS (Complete if different from spouse)
Page 2		COUNTY or PARISH/ COUNTY or PARISH
Page 2		NAME OF DEPENDENTS (Include only dependents that can be claimed on your tax return) – explain any difference / AGE / RELATIONSHIP (child, parent, etc.)/ Contributes to household income – select one __________________ / _________________/ _________________ / YES NO __________________ / _________________/ _________________ / YES NO __________________ / _________________/ _________________ / YES NO __________________ / _________________/ _________________ / YES NO
Page 3		EMPLOYMENT INFORMATION
Page 3		PRESENT EMPLOYER’S NAME (Attach last 2 pay stubs) / PRESENT EMPLOYER’S NAME (SPOUSE/PARTNER)(Attach last 2 pay stubs)
Page 3		POSITION HELD & NO. OF YEARS / POSITION HELD & NO. OF YEARS
Page 3		OTHER INCOME Enter Monthly Gross Income (Include information for yourself, spouse, partner, children and anyone else who contributes to your household income.) ** Attach entire Schedule C and /or Schedule E from your Federal Tax Return. NAME NAME NAME NAME
Page 3		Each of these types are listed on separate lines: **Self-Employment, Commisions, Tips, Interest Income, Dividend Income, **Rental Income, **Business Income, Unemployment Compensation, Pensions, Annuities, Other Retirement, Alimony Received, Child Support, Other Income (list type), Other Income (list type), Other Other Income (list type), Income (list type)
Page 4		BENEFITS Enter Monthly Benefit Amount (Include information for yourself, spouse, partner, children and anyone else who contributes to your household income.
Page 4		Attach Benefits Statement(s) / NAME / NAME / NAME / NAME
Page 4		Each of these types are listed on separate lines: Social Security Disability (SSD or SSDI), Supplemental Security Income (SSI), Disability, SNAP, Food Stamps , Rental Assistance , Other: **Each benefit line has 4 columns to input for each individual contributing to household income
Page 4		FOOD, CLOTHING & OTHER EXPENSES
Page 4		(Enter Monthly Expense Amount)
Page 3		(Include information for yourself, spouse, partner, children and anyone else who contributes to your household income.
Page 4		EXPENSE TYPE/ COST PER MONTH/ EXPENSE TYPE/ COST PER MONTH
Page 4		Food / $ / Housekeeping Supplies / $
Page 4		Apparel & Services / $ / Personal Care Products & Services
Page 4		HEALTH CARE EXPENSES ‐ OUT OF POCKET
Page 4		(Enter Monthly Expenses Amount)
Page 4 Page 3		(Include information for yourself, spouse, partner, children and anyone else who contributes to your household income.
Page 4		EXPENSE TYPE/ COST PER MONTH/ EXPENSE TYPE/ COST PER MONTH
Page 4		Medical Premiums/ $ / Medical Supplies/ $
Page 4		Prescription Drugs / $ / Medical Co‐Pays/Deductibles/ $
Page 5		HOUSING & UTILITY EXPENSES
Page 5		(Enter Monthly Expenses Amount)
Page 5 Page 3		(Include information for yourself, spouse, partner, children and anyone else who contributes to your household income.
Page 5		EXPENSE TYPE/ COST PER MONTH/ EXPENSE TYPE/ COST PER MONTH
Page 5 Page 3	AMT. OWED $ MKT. VALUE$ MO. PYMT$ NO YES (Value) $	Each of these types are listed on separate lines: Mortgage or Rent Payment $ Water/Sewer $/ Insurance (only if not included in mortgage) $ Garbage Collection/ Real Estate taxes ( only if not included in mortgage payment) $ Residential Telephone $ / Maintenance /Repairs $ Cell Phone Service $/ Gas, Propane, other heating oil $ Cable Television (basic plan) $ / Electricity $ Internet Service $
Page 5		OTHER EXPENSES
Page 5		(Enter Monthly Expenses Amount)
Page 5 Page 4		(Include information for yourself, spouse, partner, children and anyone else who contributes to your household income.
Page 5		EXPENSE TYPE/ COST PER MONTH/ EXPENSE TYPE/ COST PER MONTH
Page 5 Page 4		Each of these types are listed on separate lines: SBA Loan $ Child Support (court ordered) $ / Student Loan $ Alimony (court ordered) $
Page 5		TRANSPORTATION EXPENSES
Page 5		(Enter Monthly Expenses Amount)
Page 5 Page 4		(Include information for yourself, spouse, partner, children and anyone else who contributes to your household income.
Page 5		EXPENSE TYPE/ COST PER MONTH/ EXPENSE TYPE/ COST PER MONTH
Page 5		Public Transportation / $ / Other: / $
Page 5		VEHICLES: (Make, Model & Year) / Monthly Lease or Loan Payment / Balance Due on Loan
Page 6		PROPERTY AND OTHER ASSETS
Page 6		HOUSING: Do you Rent by Month? _ Yes _ No
Page 6		IF YOU OWN YOUR HOME: Address:_______________ Market Value: $________ Mortgage Balance $_______
Page 6		DO YOU OWN OTHER REAL ESTATE (other than primary residence _ Yes _No Address:_______________ Market Value: $________ Mortgage Balance $_______ Address:_______________ Market Value: $________ Mortgage Balance $_______
Page 6		DO YOU OWN STOCKS, BONDS or OTHER ASSETS? (Do not include Tax Deferred Retirement Accounts) Type/Account: ________$_______(Value) Type/Account______$_______(Value) Type/Account: ________$_______(Value) Type/Account______$_______(Value)
Page 6		CASH ACCOUNTS
Page 6		CHECKING________________­­­­­­­­­______________________$______________________ (Bank name, Address, and Account Number) (Average Balance) SAVINGS________________­­­­­­­­­______________________$______________________ (Bank name, Address, and Account Number) (Average Balance) OTHER________________­­­­­­­­­______________________$______________________ (Bank name, Address, and Account Number) (Average Balance)
Page 6		HOW DO YOU PROPOSE TO PAY YOUR DEBT TO THE UNITED STATES? Provide the below information in the even your financial evaluation finds that you are eligible for a payment plan. We can not guarantee that your monthly payment will be the amount you propose.
Page 6		I WILL PAY $___________________ PER MONTH BEGINNING ___________(Date)

Page 4		Type/Account: $ (Value) Type/Account: $
Page 4		Type/Account: $ (Value) Type/Account: $
Page 4		CASH ACCOUNTS
Page 4		(Include information for yourself, spouse, partner, children and anyone else who contributes to your household income.
Page 5		CHECKING:(Bank Name, Address and Account Number) /(Average Balance)$
Page 5		SAVINGS:(Bank Name, Address and Account Number) /(Average Balance)$
Page 5		OTHER:(Bank Name, Address and Account Number) /(Average Balance)$
Page 5		HOW DO YOU PROPOSE TO PAY YOUR DEBT TO THE UNITED STATES?
Page 5		I WILL PAY$ PER MONTH BEGINNING (Date)
Page 5		If you require additional space to answer any questions, please include the information on a separate sheet of paper and attach to this form