"Financial Statement of Debtor"

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U.S. Department of Justice
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 back of last page.
FINANCIAL STATEMENT OF DEBTOR
Authority for the solicitation of the requested information is one or more of the following: 5 U.S.C. 301, 901 (see Note, Executive Order 6166, June 10, 1933);
28 U.S.C. 501, et seq.; 31 U.S.C. 951, et seq.; 44 U.S.C. 3101; 4 CFR 101, et seq.; 28 CFR 0.160, 0.171 and Appendix to Subpart Y. Fed.R.Civ.P. 33(a), 28
U.S.C. 1651, 3201 et seq.
The principal purpose for gathering this information is to evaluate your ability to pay the Government’s claim or judgment against you. Routine
uses of the information are established in the following U.S. Department of Justice Case File Systems published in Vol. 42 of the Federal Register;
Justice/CIV-001 at page 5332; Justice/TAX-001 at page 15347; Justice/USA-005 at pages 53406-53407; Justice/USA-007 at pages 53408-53410;
Justice/CRIM-016 at page 12274. Disclosure of the information is voluntary. If the requested information is not furnished, the U.S. Department of Justice has
the right to such disclosure of the information by legal methods.
__________________________________________________________________________________________
Section 1
1. Full Name(s) _________________________________
1a. Home Telephone: (____) _________________
Personal
_________________________________
Best Time to Call _______a.m. ______ p.m.
Information
Street Address
_________________________________
1b. Cellular Number: (____) _________________
City______________________State______ Zip_________
2. Marital Status:
County of Residence_______________________________
G
Married
G
Separated
How long at this residence?
___________________
G
Unmarried (single, divorced, widowed)
____________________________________________________________________________________________
3. Your Social Security No. (SSN) ___________________
3a. Your Date of Birth (mm/dd/yy)______________
4. Spouse’s Social Security No.
___________________
4a. Spouse’s Date of Birth (mm/dd/yy)___________
___________________________________________
___________________________________________
______
5.
G
Own Home
G
Rent
G
Other (specify, i.e. share rent, live with relative)_______________________________
____________________________________________________________________________________________
6. List the dependants you can claim on your tax return: (Attach sheet if more space is needed)
First Name
Relationship
Age
Does this person
First Name
Relationship
Age
Does this person
live with you?
live with you?
___________________________
Q
Q
___________________________
Q
Q
No
Yes
No
Yes
___________________________
Q
Q
___________________________
Q
Q
No
Yes
No
Yes
___________________________________________________________________________________________________________
Section 2
7. Are you or your spouse self-employed or operate a business? (Check “Yes” if either applies)
Your
G
No
G
Yes If yes, provide the following information:
Business
7a. Name of Business
____________________________ 7c. Employer Identification No:________________
Information
7b. Street Address
____________________________ 7d. Do you have employees?
Q
No
Q
Yes
City________________________State______ Zip_________ 7e. Do you have accounts receivable?
Q
No
Q
Yes
If yes, please complete section 8 on page 5.
L
ATTACHMENTS REQUIRED: Please provide proof of self-employment income for the prior 3 months
(e.g. invoices, commissions, sales records, income statement).
___________________________________________________________________________________________________________
Section 3
8. Your employer___________________________________ 9. Spouse’s Employer_________________________
Employment
Street Address
___________________________________ Street Address
____________________________
Information
City________________________State______ Zip_________ City_________________State______ Zip_________
Work telephone no. (____)____________________
Work telephone no. (____)_____________________
May we contact you at work?
Q
No
Q
Yes
May we contact you at work?
Q
No
Q
Yes
8a. How long with this employer? ______________________ 9a. How long with this employer?________________
8b. Occupation_____________________________________ 9b. Occupation______________________________
L
ATTACHMENTS REQUIRED: Please provide proof of gross earnings and deductions for the past 3 months from each employer (e.g.
pay stubs, earnings statements). If year-to-date information is available, send only 1 such statement as long as a minimum of 3 months is
represented.
U.S. Department of Justice
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 back of last page.
FINANCIAL STATEMENT OF DEBTOR
Authority for the solicitation of the requested information is one or more of the following: 5 U.S.C. 301, 901 (see Note, Executive Order 6166, June 10, 1933);
28 U.S.C. 501, et seq.; 31 U.S.C. 951, et seq.; 44 U.S.C. 3101; 4 CFR 101, et seq.; 28 CFR 0.160, 0.171 and Appendix to Subpart Y. Fed.R.Civ.P. 33(a), 28
U.S.C. 1651, 3201 et seq.
The principal purpose for gathering this information is to evaluate your ability to pay the Government’s claim or judgment against you. Routine
uses of the information are established in the following U.S. Department of Justice Case File Systems published in Vol. 42 of the Federal Register;
Justice/CIV-001 at page 5332; Justice/TAX-001 at page 15347; Justice/USA-005 at pages 53406-53407; Justice/USA-007 at pages 53408-53410;
Justice/CRIM-016 at page 12274. Disclosure of the information is voluntary. If the requested information is not furnished, the U.S. Department of Justice has
the right to such disclosure of the information by legal methods.
__________________________________________________________________________________________
Section 1
1. Full Name(s) _________________________________
1a. Home Telephone: (____) _________________
Personal
_________________________________
Best Time to Call _______a.m. ______ p.m.
Information
Street Address
_________________________________
1b. Cellular Number: (____) _________________
City______________________State______ Zip_________
2. Marital Status:
County of Residence_______________________________
G
Married
G
Separated
How long at this residence?
___________________
G
Unmarried (single, divorced, widowed)
____________________________________________________________________________________________
3. Your Social Security No. (SSN) ___________________
3a. Your Date of Birth (mm/dd/yy)______________
4. Spouse’s Social Security No.
___________________
4a. Spouse’s Date of Birth (mm/dd/yy)___________
___________________________________________
___________________________________________
______
5.
G
Own Home
G
Rent
G
Other (specify, i.e. share rent, live with relative)_______________________________
____________________________________________________________________________________________
6. List the dependants you can claim on your tax return: (Attach sheet if more space is needed)
First Name
Relationship
Age
Does this person
First Name
Relationship
Age
Does this person
live with you?
live with you?
___________________________
Q
Q
___________________________
Q
Q
No
Yes
No
Yes
___________________________
Q
Q
___________________________
Q
Q
No
Yes
No
Yes
___________________________________________________________________________________________________________
Section 2
7. Are you or your spouse self-employed or operate a business? (Check “Yes” if either applies)
Your
G
No
G
Yes If yes, provide the following information:
Business
7a. Name of Business
____________________________ 7c. Employer Identification No:________________
Information
7b. Street Address
____________________________ 7d. Do you have employees?
Q
No
Q
Yes
City________________________State______ Zip_________ 7e. Do you have accounts receivable?
Q
No
Q
Yes
If yes, please complete section 8 on page 5.
L
ATTACHMENTS REQUIRED: Please provide proof of self-employment income for the prior 3 months
(e.g. invoices, commissions, sales records, income statement).
___________________________________________________________________________________________________________
Section 3
8. Your employer___________________________________ 9. Spouse’s Employer_________________________
Employment
Street Address
___________________________________ Street Address
____________________________
Information
City________________________State______ Zip_________ City_________________State______ Zip_________
Work telephone no. (____)____________________
Work telephone no. (____)_____________________
May we contact you at work?
Q
No
Q
Yes
May we contact you at work?
Q
No
Q
Yes
8a. How long with this employer? ______________________ 9a. How long with this employer?________________
8b. Occupation_____________________________________ 9b. Occupation______________________________
L
ATTACHMENTS REQUIRED: Please provide proof of gross earnings and deductions for the past 3 months from each employer (e.g.
pay stubs, earnings statements). If year-to-date information is available, send only 1 such statement as long as a minimum of 3 months is
represented.
Name_____________________________________
SSN______________________
Page 2
__________________________________________________________________________________________
Section 4
10. Do you receive income from sources other than your own business or your employer? (Check all that apply.)
Other
Income
G
Pension
G
Social Security
G
Other (specify, e.g. child support, alimony, rental)_______________
Information
L
ATTACHMENTS REQUIRED: Please provide proof of pension/social security/other income for the past 3 months from each payor,
including any statements showing deductions. If year-to-date information is available, send only 1 statement as long as 3 months is represented.
____________________________________________________________________________________________________________________________________
Section 5
11. CHECKING ACCOUNTS. List all checking accounts. (If you need additional space, attach a separate sheet.)
Banking,
Type of
Full name of Bank, Credit
Current Account
Investment,
Account
Union or Institution
Bank Account No.
Balance
Cash, Credit
11a.
Checking
Name_____________________
___________________
$______________
and Life
Address____________________
Insurance Information
City/State/Zip_______________
11b.
Checking
Name______________________
___________________
$______________
Address____________________
City/State/Zip_______________
11c.
Total Checking Accounts Balances
$
0.00
____________________________________________________________________________________________
12. OTHER ACCOUNTS. List all accounts, including brokerage, savings and money market, not listed in 11.
Type of
Full name of Bank, Credit
Current Account
Account
Union or Institution
Bank Account No.
Balance
12a.
__________
Name_____________________
___________________
$______________
Address____________________
City/State/Zip_______________
12b.
__________
Name______________________
___________________
$______________
Address____________________
City/State/Zip_______________
12c.
Total Other Account Balances
0.00
L
ATTACHMENTS REQUIRED: Please include your current bank statements (checking, savings, money market and brokerage accounts)
for the past 3 months for all accounts.
____________________________________________________________________________________________
13. INVESTMENTS. List all investment assets below. Include stocks, bonds, mutual funds, stock options,
certificates of deposits and retirement assets such as IRAs, Keogh and 401(k) plans.
Number of
Current
Loan
Used as collateral
Name of Company
Shares/Units
Value
Amount
on loan?
(if any)
13a.
__________________________
____________
$____________ $___________
G
No
G
Yes
13b.
__________________________
____________
$____________ $___________
G
No
G
Yes
13c.
__________________________
____________
$____________ $___________
G
No
G
Yes
13d. Total Investments
0.00
__________________________________________________________________________________________________________
14. CASH ON HAND. Include any money that you have that is not in the bank.
14a. Total Cash on Hand
Name_____________________________________
SSN______________________
Page 3
__________________________________________________________________________________________________________
Section 5
15. AVAILABLE CREDIT. List all lines of credit, including credit cards. ( If you need additional space, attach a
continued
separate sheet.)
Full Name of
Minimum
Credit Institution
Credit Limit
Amount Owed
Payment
15a.
Name___________________________
___________
______________
$____________
Address_________________________
City/State/Zip_____________________
15b.
Name___________________________
___________
______________
$____________
Address_________________________
City/State/Zip_____________________
0.00
15c. Total Minimum Payments
____________________________________________________________________________________________
16. LIFE INSURANCE. Do you have life insurance with a cash value?
G
No
G
Yes
(Term Life Insurance does not have a cash value.)
16a. Name of Insurance Company__________________________________________________
16b. Policy Number(s)___________________________________________________________
16c. Owner of Policy____________________________________________________________
16d. Current Cash Value $___________________
16e. Outstanding Loan Balance $____________________
0.00
Subtract “Outstanding Loan Balance: line 16e from “Current Cash Value” line 16d = 16f
L
ATTACHMENTS REQUIRED: Please include a statement from the life insurance companies that includes type and cash/loan
value amounts. If currently borrowed against, include loan amount and date of loan.
___________________________________________________________________________________________________________
Section 6
17. OTHER INFORMATION. Respond to the following questions related to your financial condition:
Other
(Attach a separate sheet if you need more space.)Information
17a. Do you have a safe deposit box?
G
No
G
Yes
If yes, please include the name and address of location of box, the box number and the contents below:
____________________________________________________________________________________________
____________________________________________________________________________________________
17b. Do you have a will?
G
No
G
Yes; if yes, where is it kept?_______________________________________
17c. Are there any garnishments against your wages?
G
No
G
Yes
If yes, who is the creditor?___________________ Date of Judgment____________ Amount of debt $_______
17d. Are there any judgments against you?
No
Yes
G
G
If yes, who is the creditor?___________________ Date of Judgment____________ Amount of debt $_______
17e. Are you a party to a lawsuit?
No
Yes
G
G
If yes, amount of suit $____________ Possible completion date_____________
Court________________
Subject matter of suit________________________________________________________________________
17f. Did you ever file bankruptcy?
No
Yes
G
G
If yes, date filed_______________________
Date discharged ___________________
17g. In the past 10 years did you transfer any assets out of your name for less than their actual value?
No
Yes
G
G
If yes, what asset?_____________________________ Value of asset at time of transfer $_________________
When was it transferred?_________________ To whom was it transferred? ____________________________
17h. Do you anticipate any increase in household income in the next 2 years?
No
Yes
G
G
If yes, why will the income increase?____________________________ (Attach sheet if you need more space.)
How much will it increase? ___________________________________
17i. Are you a beneficiary of a trust or an estate?
G
No
G
Yes
If yes, name of the trust or estate____________________ Anticipated amount to be received $____________
When will the amount be received?____________________
17j. Are you a participant in a profit sharing plan?
G
No
G
Yes
If yes, name of plan____________________________________ Value in plan $__________________
Name_____________________________________
SSN______________________
Page 4
__________________________________________________________________________________________
Section 7
18. PURCHASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s,
Assets and
motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)
Liabilities
Current
Description
*Current
Loan
Name of
Purchase
Monthly
(year, make, model)
Value
Balance
Lender
Date
Payment
*Current
Value is
18a.
____________________
____________
___________
$______
the amount
____________________
you could
____________________
sell the
asset for today
18b.
____________________
____________
___________
$______
____________________
____________________
LEASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s,
motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)
Name and
Description
Lease
Address of
Lease
Monthly
(year, make, model)
Balance
Lessor
Date
Payment
18c.
____________________
_____________________
__________ $________
____________________
____________________
18d.
____________________
_____________________
__________ $________
____________________
_____________________
L
ATTACHMENTS REQUIRED: Please include your current statement from lender with monthly car payment and current
balance of the loan for each vehicle purchased or leased.
____________________________________________________________________________________________
20. REAL ESTATE. List all real estate you own. (If you need additional space, attach a separate sheet.)
Street Address, City
State, Zip, County
Date
Purchase
*Current
Loan
Monthly
Lender/Lien Holder
Purchased
Price
Value
Balance
Pymt
20a.______________________
____________
$_________
$________
_________________________
_________________________
20b.______________________
____________
$_________
$________
_________________________
_________________________
____________________________________________________________________________________________
21. PERSONAL ASSETS.
List all personal assets below. (If you need additional space, attach a separate sheet.)
Furniture/Personal effects includes the total current market value of your household such as furniture and appliances
Other Personal Assets includes all artwork, jewelry, collections, antiques or other assets
Current
Loan
Monthly
Date of
Description
Value
Balance
Lender
Payment
Final Pymt
21a.
Furniture/Personal Effects $___________
$__________
_____________ $_________ _________
Other: (List below)
21b.
Artwork
$___________
$__________
_____________ $_________ _________
21c.
Jewelry
$___________
$__________
_____________ $_________ _________
21d.
____________________ $___________
$__________
_____________ $_________ _________
21e.
____________________ $___________
$__________
_____________ $_________ _________
Name_____________________________________
SSN______________________
Page 5
__________________________________________________________________________________________________________
Section 7
continued
22. BUSINESS ASSETS.
List all business assets and encumbrances below, include Uniform Commercial Code filings. (If you need
additional space, attach a separate sheet.) Tools used in Trade or Business includes the basic tools or books used to conduct your business,
excluding automobiles. Other Business Assets includes machinery, equipment, inventory or other assets.
Current
Loan
Monthly
Date of
Description
Value
Balance
Lender
Payment
Final Pymt
22a.
Tools used in Trade/
Business
$___________
$__________
_____________ $_________ _________
Other: (List below)
22b.
Machinery
$___________
$__________
_____________ $_________ _________
22c.
Equipment
$___________
$__________
_____________ $_________ _________
22d.
____________________ $___________
$__________
_____________ $_________ _________
22e.
____________________ $___________
$__________
_____________ $_________ _________
__________________________________________________________________________________________
Section 8
23. ACCOUNTS/NOTES RECEIVABLE. List all accounts separately, including contracts awarded, but not
Accounts/
started. (If you need additional space, attach a separate sheet.)
Notes
Receivable
Description
Amount Due
Date Due
Age of Account
Use only if
23a.
Name_____________________________
$__________
___________
Q
0-30 days
needed
Address___________________________
Q
30-60 days
City/State/Zip_______________________
Q
60-90 days
Q
90+ days
____________________________________________________________________________________________
23b.
Name_____________________________
$__________
___________
Q
0-30 days
Address___________________________
Q
30-60 days
City/State/Zip_______________________
Q
60-90 days
Q
90+ days
____________________________________________________________________________________________
23c.
Name_____________________________
$__________
___________
Q
0-30 days
30-60 days
Address___________________________
Q
City/State/Zip_______________________
60-90 days
Q
90+ days
Q
____________________________________________________________________________________________
23d.
Name_____________________________
$__________
___________
0-30 days
Q
Address___________________________
30-60 days
Q
City/State/Zip_______________________
60-90 days
Q
90+ days
Q
____________________________________________________________________________________________
23e.
Name_____________________________
$__________
___________
0-30 days
Q
Address___________________________
30-60 days
Q
City/State/Zip_______________________
60-90 days
Q
90+ days
Q
____________________________________________________________________________________________
23f.
Name_____________________________
$__________
___________
Q
0-30 days
Address___________________________
Q
30-60 days
City/State/Zip_______________________
Q
60-90 days
Q
90+ days
Add “Amount Due” from lines 23a through 23f = 23g
0.00
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