Financial Statement of Debtor

(Submitted for Government Action on Claims Due the United States)

Instructions:

1) Complete all blocks. Write “N/A” in blocks that do not apply.

2) Use additional sheets or back of page where space is insufficient.

3) Must provide with this financial statement:

a. last two pay stubs

b. last tax return

c. proof of major expenses listed in “Fixed Monthly Expenses”

4) Submit documentation to:

Privacy Act Notice: We are asking you for this information pursuant to the U. S. Department of the Treasury's authority 

to collect debts owed to the United States, which is found at 31 U.S.C. 321, 3701 et seq., and 31 C.F.R. parts 285 and 

parts 900-904. The principal purpose for gathering this information is to evaluate your ability to pay the Government's 

claim or judgment against you. This information may be disclosed to other Federal agencies, credit bureaus, and 

private collection agencies for the purpose of collecting debt(s) owed by you to the United States. Your name and social 

security number may be disclosed to your employer if we decide to garnish your wages to collect debt(s) owed by you 

to the United States. This information may also be disclosed to a court, magistrate, congressional office, or a Federal, 

state, or local government agency, as authorized or required by Federal law. We are required to ask you for your social 

security number pursuant to 31 U.S.C. 7701(c)(1). Your social security number will be used for purposes of collecting 

and reporting on any delinquent amounts you owe to the United States. Disclosure of your financial information is 

voluntary. However, if the requested information is not furnished, the U.S. Department of the Treasury may not be able 

to resolve your debt pursuant to a mutual agreement, and we may ask the Department of Justice to obtain disclosure of 

the information by legal methods. 

A. Personal Identification

Name (Debtor): Birth Date (M/D/Y): Social Security Number: 

Home Address

Street 1: 

Street 2: 

City: 

State: 

Zip Code: 

Driver’s License Number and State: 

Home Phone: Ext: 

Email:

B. Employment

Present Employer’s Name: Employer’s Phone Number: 

Employer’s Address

Street 1: 

Street 2: 

City: 

State: 

Zip Code: 

Job Title: 

Present Employment Length: 

List other current employers and any you have had in the last 3 years:

FS Form 000123

OMB No. 1530-0075
C. Monthly Income and Expenses

• Must attach a copy of last two paystubs and proof of major expenses

• Additional documentation may be requested if expenses or income fall outside expected amounts

INCOME EXPENSES

Gross Salary1 (Before Deductions) 

Gross Salary2 (Before Deductions) 

OTHER INCOME SOURCES

Commission 

Alimony Received 

Child Support Received 

Net Rental Income 

Interest/dividends 

Personal Income from Business 

Pension income 

Insurance annuity 

Disability or SSI 

Unemployment 

Other Income: 

---all expenses should be calculated as monthly--

Rent/Mortgage

Home Hazard Insurance

Local Home Taxes (if paid separately from mortgage)

Childcare (Daycare)

Car Payment

Car Insurance

Public Transportation

Gasoline

Electricity

Cable TV

Internet

Telephone (Landline + Cell)

Natural Gas

Water

Trash

Other Utilities (Specify) 

Food

Clothing

Child support paid

Alimony paid

Student Loan/s

Medical expenses (out-of-pocket)

Credit Card/s (min. amount due)

Other (Specify) 

Other (Specify) 

Deductions

(Deductions per time period on paystub or documents)

Federal Taxes

State/County/City Taxes

Social Security Taxes (FICA/Medicare)

Medical Insurance

Union Dues (If applicable)

Life Insurance

Allotments to Bank or Fin. Institutions

Other payroll deductions (401k)

Total Monthly Take home pay 

(Gross Salary + Other Income – Deductions) 

Total Monthly Expenses

(Sum of all of above)
D. SPOUSE/COMPANION

• By providing this information, you are not indicating spouse liability for invoice

• Spouse information is voluntary, however if bills listed in spouse name, their income is required.

• If not married but have a live-in companion, you may choose to furnish information on this companion below.

Current Spouse’s Name: Birth Date (mm/dd/yy): 

If spouse’s home address is different, list:

Employer Name: Employer Phone: Employment length: 

Job Title: Gross salary: $ Take home pay: $ 

E. DEPENDENTS

Name Age Relationship

F. TAXES

• Must attach a copy of your last filed Federal income tax form

Did you file a Federal Income Tax Return last year? ☐ Yes ☐ No

If Yes, ☐ Joint ☐ Individual Amount of Gross Income on return was $ 

Are you or did you receive a tax refund from Federal, State, City or County? ☐ Yes ☐ No

If yes, list from whom and amount for each refund: 

Entity: $ Entity: $ 

Entity: $ Entity: $

Do you owe delinquent taxes? ☐ Yes ☐ No If yes, list below, years and amounts due:

Entity: Year: Amount Due: $

Entity: Year: Amount Due: $

G. ASSETS

REAL PROPERTY: FARM/LAND/VACATION HOME/RENTAL

Are you buying the home in which you live? ☐ Yes ☐ No

Are you buying or do you own real property other than your home? ☐ Yes ☐ No

Property Description Value Equity

Is any of the above property owned jointly another? ☐ Yes ☐ No If yes, list property and the name of the co-owner:

Property: Co-Owner: Property: Co-Owner: 

CASH

Provide name of the bank or financial institution, and the amount in each account or on deposit:

Name of Bank or Institution Balance Name of Bank or Institution Balance

Check Account $ Money Market Account $

Savings Account $ Certificate of Deposit $

Credit Union Account $ IRA or Keogh Account $ 
OTHER ASSETS 

Do you or your spouse/companion own U. S. Savings Bonds? ☐ Yes ☐ No Value: $

Do you own stocks or other types of bonds? ☐ Yes ☐ No If yes, list details below

Name of Issuer Address of Issuer Value 

$

$

List automobiles owned or being purchased by you, your spouse/companion or dependent: 

Model/Year Make/License Number Value 

$

$

$

$

List other assets by Type: 

Camper/Recreational Vehicle Value: $ Antiques, art collection Value: $ 

Boat, Motorcycle, or Motorbike Value: $ Jewelry valued over $5,000 Value: $ 

Is any of the property listed above owned jointly with anyone else? ☐ Yes ☐ No

If yes, with whom:

H. ITEMS WHICH MIGHT AFFECT FUTURE ASSETS:

Are you involved in a lawsuit in which you might receive money or something of value: ☐ Yes ☐ No

If yes, state where the suit is filed and what it involves (include Court number and caption):

Are you a Trustee, Executor, or Administrator of an estate? ☐ Yes ☐ No

If yes, give details:

If anyone holding money on your behalf? ☐ Yes ☐ No

If yes, give specific details:

If there any likelihood you will receive an inheritance? ☐ Yes ☐ No

If yes, give specific details:

Have you sold or transferred either real property or stocks and bonds in the past three years? ☐ Yes ☐ No

If yes, give specific details:

Are your wages and/or those of your spouse/companion under garnishment at this time? ☐ Yes ☐ No

If yes, give specific details:

Are there any outstanding unpaid judgments against you for debts other than this one? ☐ Yes ☐ No

If yes, give specific details and attach copies of the bills.

Do you owe large medical bills? ☐ Yes ☐ No

If yes, give specific details and attach copies of the bills.

With knowledge of the penalties for false statements provided by 18 United State Code 1001 ($10,000 fine 

and/or five years imprisonment) and with knowledge that this financial statement is submitted by me to affect

action by the U. S. Department of Treasury, I certify that I believe the above statement is true and that it is a 

complete statement of all my income and assets, real and personal, whether held in my name or by any other.

Date: Signature: 

Date: Signature: 

Please Note: If you have added additional sheets to this form, or added information on the back of this page 

or any page, please also sign those pages.

Notice Under the Paperwork Reduction Act:

We estimate it will take you about 45 minutes to complete this form. However, you are not required to provide information 

requested unless a valid OMB control number is displayed on the form. Any comments or suggestions regarding this form 

should be sent to the Bureau of the Fiscal Service, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT 

SEND completed form to the above address; send to correct address shown in “Where to send” in the Instructions.