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U.S. Department of the Treasury

Financial Disclosure Statement

To evaluate a hardship claim, the U.S. Department of the Treasury (the Department) compares the expenses 

you claim and support against averages spent for those similar expenses by families of the same size and 

income as yours. The Department considers proven expenses as reasonable up to the amount of these 

averages. If you claim more for an expense than the average spent by families like yours, you must provide 

persuasive explanation why the amount you claim is necessary. These average amounts were determined by 

the Internal Revenue Service (IRS) from different government studies. You can find the average expense 

amount that the Department uses at the following Web site: www.irs.gov and then search for “Collection 

Financial Standards.” 

• Complete all items. Do not leave any item blank. If the answer is zero, write zero.

• Provide documentation of expenses. Expenses will not be considered if you do not provide documents 

supporting the amounts claimed.

• Disclose and provide documentation of household income.

• Failure to provide this information and documentation will result in a denial of your claim of financial 

hardship.

• Sign and date page 6

• Return the requested information and documentation to: 

o US DEPARTMENT OF TREASURY 

o Fax #: (512)342-7220 / (512)342-7230

o email: AWG.Hearings@fiscal.treasury.gov

Income

Your Name: ________________________

Address: ________________________ Home Phone: ____________________

 ________________________ Cell Phone: ___________________

County: ________________________ Work Phone: ____________________

Current Employer:_____________________ Date Employed: __________________

Employer Phone: __________________ Present Position: _________________

Gross Income: $ _____________________Weekly  Bi-Weekly  Monthly  Other ___________

Net Income: $ _______________________ Weekly  Bi-Weekly  Monthly  Other ___________

YOU MUST ENCLOSE: COPY OF YOUR TWO MOST RECENT PAY STUBS AND COPIES OF 

MOST RECENT W-2s AND 1040, 1040A, 1040EZ or other IRS FILING

Please list all taxes deducted from your pay.
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Deductions Amount Reason 

Federal Tax: $_______ ______________________________

State Tax: $_______ ______________________________

City/Other: $_______ ______________________________

FICA: $_______ ______________________________

Medicare: $_______ ______________________________

Other: $_______ ______________________________

401K: $_______ ______________________________

Retirement: $_______ ______________________________

Union Dues: $_______ ______________________________

Medical: $_______ ______________________________

Dental: $_______ ______________________________

Vision: $_______ ______________________________

Credit Union: $_______ ______________________________

Other: $_______ ______________________________

Other: $_______ ______________________________

Number of dependents: _______(including yourself) 

Marital status: Married  Single  Divorced

Spouse’s Income

Your spouse’s name: ___________________ 

Gross Income: $ _____________________Weekly  Bi-Weekly  Monthly  Other ___________

Net Income: $ _______________________ Weekly  Bi-Weekly  Monthly  Other ___________

YOU MUST ENCLOSE: COPY OF YOUR TWO MOST RECENT PAY STUBS AND COPIES OF 

MOST RECENT W-2s AND 1040, 1040A, 1040EZ or other IRS FILING

Please explain all deductions shown on pay-stubs: 
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Deductions Amount Reason 

Federal Tax: $_______ ______________________________

State Tax: $_______ ______________________________

City/Other: $_______ ______________________________

FICA: $_______ ______________________________

Medicare: $_______ ______________________________

401K: $_______ ______________________________

Retirement: $_______ ______________________________

Union Dues: $_______ ______________________________

Medical: $_______ ______________________________

Dental: $_______ ______________________________

Vision: $_______ ______________________________

Credit Union: $_______ ______________________________

Other: $_______ ______________________________

Other: $_______ ______________________________

Other household members(s) with income: 

Name: ___________________ 

Gross Income: $ _____________________Weekly  Bi-Weekly  Monthly  Other ___________

Net Income: $ _______________________ Weekly  Bi-Weekly  Monthly  Other ___________

YOU MUST ENCLOSE: COPY OF YOUR TWO MOST RECENT PAY STUBS AND COPIES OF 

MOST RECENT W-2s AND 1040, 1040A, 1040EZ or other IRS FILING

Please explain all deductions shown on other household member’s pay-stubs: 

Deductions Amount Reason 

Federal Tax: $_______ ______________________________

State Tax: $_______ ______________________________

City/Other: $_______ ______________________________

FICA: $_______ ______________________________
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Medicare: $_______ ______________________________

401K: $_______ ______________________________

Retirement: $_______ ______________________________

Union Dues: $_______ ______________________________

Medical: $_______ ______________________________

Dental: $_______ ______________________________

Vision: $_______ ______________________________

Credit Union: $_______ ______________________________

Other: $_______ ______________________________

Other: $_______ ______________________________

Other Income:

Child support: $ ______________ Weekly Bi-Weekly Monthly Other _____

Alimony: $ ___________________ Weekly Bi-Weekly Monthly Other _____

Interest: $ ___________________ Weekly Bi-Weekly Monthly Other ____

Public assistance: $ ___________ Weekly Bi-Weekly Monthly Other ____

Rental income: $ ___________ Weekly Bi-Weekly Monthly Other ____

Other: $ ____________________ Weekly Bi-Weekly Monthly Other ______

Describe Other: __________________________________________________________

Monthly Expenses 

Shelter (YOU MUST SEND COPY OF MORTGAGE OR LEASE)

Rent/Mortgage: $ _____________ Paid to whom: _______________________________________

2nd home mortgage: $ _____________ Paid to whom: ____________________________________

Home/Renter insurance: $ ______________

Other: $ _____________ Describe: ___________________________________________

Other: $ _____________ Describe: ___________________________________________

Other: $ _____________ Describe: ___________________________________________

Food and Household Expenses
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FOOD: $ _______________/month

Clothing: $ _______________/month

Utilities (SEND COPIES OF BILLS)

Electric: $ ______________

Gas: $ ______________

Water/Sewer: $ ______________

Garbage pickup: $ ______________

Telephone: $ ______________

Cell Phone $ ______________

Internet $ ______________

Other: $ _______________ Describe: ______________________

Other: $ _______________ Describe: ______________________

Medical (YOU MUST SEND COPIES OF BILLS)

Insurance $___________ /per month 

(Only list payments not deducted from paycheck) 

Bill payments $ ________________/per month 

(Only list payments not covered by insurance) 

Other: $ ________________/per month 

Describe: ___________________________________________________________ 

Transportation (YOU MUST SEND COPIES OF CAR PAYMENT AGREEMENT OR BILLS)

# of cars: ___________

1st Car payment: $ ____________ /per month 

2nd Car payment: $ ____________ /per month 

Gas and oil: $_____________/per month 

Public transportation: $_____________ /per month 

Tolls: $_____________ /per month

Car insurance: $________________ /per month 

Other: $ _________________ Describe: _____________________________________ 

Child/Dependent Care (YOU MUST SEND COPIES OF BILLS)

Child/Dependent care: $ ___________ /per month Number of children: ________

Child support: $ _________/per month Number of children: ________

Other: $ ___________/per month Describe: ________________________
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Other Expenses (YOU MUST SEND COPIES OF BILLS)

Other Insurance: $ ____________ Describe: ______________

Tax Debt: $____________ Describe: ______________

Student Loans____________ Describe: ______________

Miscellaneous Expenses (Attach a list describing expense, monthly payment and enclose bills)

SIGNATURE 

I declare under penalty of law that the answers and statements contained herein are true and correct. 

Signature __________________________ Date _________

Warning: 18 U.S.C. 1001 provides that “whoever...knowingly and willfully falsifies, conceals or covers 

up by any trick, scheme, or device a material fact, or makes any materially false, fictitious, or fraudulent 

statement or representation...shall be fined up to $10,000.00 or imprisoned up to five years, or both”.

Privacy Act Notice 

This request is authorized under 31 U.S.C. 3711, 20 U.S.C. 1078-6, and 31 U.S.C. 3720D. You are not 

required to provide this information. If you do not, we cannot determine your financial ability to repay 

your federal debt. The information you provide will be used to evaluate your ability to pay. It may be 

disclosed to government agencies and their contractors, to employees, lenders, and others to enforce 

this debt; to third parties in audit, research, or dispute about the management of this debt; and to 

parties with a right to this information under the Freedom of Information Act or other Federal law, or 

with your consent. These uses are explained in Notice for System of Records 18-11-07, 64 FR 30166 

(June 4, 1999), 64 FR 72407 (Dec. 27, 1999). We will send a copy at your request.