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_______________________________ GMarried GSeparated
How long at this residence? ___________________ GUnmarried (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 GRent GOther (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?
___________________________ ___________________________
QNo QYes QNo QYes
___________________________ ___________________________
QNo QYes QNo QYes
___________________________________________________________________________________________________________

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 (if any) on loan?
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_____________________

15c. Total Minimum Payments 0.00

____________________________________________________________________________________________
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 $____________________

Subtract “Outstanding Loan Balance: line 16e from “Current Cash Value” line 16d = 16f 0.00

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? G No G Yes
If yes, who is the creditor?___________________ Date of Judgment____________ Amount of debt $_______
17e. Are you a party to a lawsuit? G No G Yes
If yes, amount of suit $____________ Possible completion date_____________ Court________________
Subject matter of suit________________________________________________________________________
17f. Did you ever file bankruptcy? G No G Yes
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?
G No G Yes
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? G No G Yes
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
Address___________________________ Q 30-60 days
City/State/Zip_______________________ Q 60-90 days
Q 90+ days
____________________________________________________________________________________________
23d. Name_____________________________ $__________ ___________ Q 0-30 days
Address___________________________ Q 30-60 days
City/State/Zip_______________________ Q 60-90 days
Q 90+ days
____________________________________________________________________________________________
23e. Name_____________________________ $__________ ___________ Q 0-30 days
Address___________________________ Q 30-60 days
City/State/Zip_______________________ Q 60-90 days
Q 90+ days
____________________________________________________________________________________________
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
Name____________________________________________________ SSN_________________________ Page 6
___________________________________________________________________________________________________________________________________

Section 9 Total Income Total Living Expenses

Monthly Source Gross monthly Expense Items1 Actual Monthly
Income and 24. Wages (yourself) $ 35. Rent/Mortgage $
Expense 25. Wages (spouse) 36. Electric
Analysis 26. Interest - Dividends 37. Natural Gas
27. Net Business Income 38. Cable TV
If only one 28. Net Rental Income 39. Telephone
spouse has 29. Pension/Social Security 40. Water
a debt, but 30. Pension/Social Security 41. Food
both have (Spouse) 42. Car Payment
income, list 31. Child Support 43. Gasoline
the total 32. Alimony 44. Car Insurance
household 33. Other 45. Cell Phone/Pager
income and 34. Total Income $ 0.00 46. Other Utilities
expenses. 47. Clothing & Misc.
48. Health Care
49. Court Ordered Payments
50. Child/Dependant Care
51. Life Insurance
52. Other secured debt
53. Other expenses
54. Education Expenses
55. Total Living Expenses $ 0.00

L ATTACHMENTS REQUIRED: Please include;

• A copy of your last Form 1040 with all Schedules
• Proof of all current expenses that you paid for the last 3 months, including utilities, rent, insurance, property taxes, etc.
• Proof of all non-business transportation expenses (e.g car payments, lease payments, fuel, oil, insurance, parking, registration)
• Proof of payments for health care, including health insurance premiums, co-payments and other out-of-pocket expenses
• Copies of any court order requiring payment and proof of such payments for the past 3 months

___________________________________________________________________________________________________________

CERTIFICATION

I declare that I have examined the information given in this statement and, to the best of my knowledge and belief, it is true, correct,
and complete, and I further declare that I have no assets, owned either directly or indirectly, or income of any nature other that as
shown in this statement, including any attachment.

________________________________________________________________________________________________________
Signature Social Security No. Date

WARNING

False statements are punishable up to five years imprisonment, a fine of $250,000, or both pursuant to 18 U.S.C. §1001.

1
Expenses generally not allowed: We generally do not allow you to claim tuition for private schools, public
or private college expenses, charitable donations, voluntary retirement contributions, payments on unsecured debts
such as credit card bills and other similar expenses. However, we may allow these expenses, if you can prove that
they are necessary for the health and welfare of you or your family.