Us Dept Of Justice Financial Statement Form – Fill Out and Use This PDF

The U.S. Department of Justice Financial Statement of Debtor form is a crucial document for those who owe claims to the United States government. It is designed to gather comprehensive information about an individual's or a business’s financial status to assess their ability to settle government claims or judgments. This form requires detailed disclosures ranging from personal information, employment details, income sources, assets, liabilities, to other relevant financial data. For those needing to submit their financial particulars for government claims, start by clicking the button below to fill out the form accurately.

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Us Dept Of Justice Financial Statement Form PDF Details

For individuals or entities indebted to the U.S. government, the U.S. Department of Justice Financial Statement of Debtor form represents a critical document required for government action on claims due. Essential for assessing the debtor's ability to settle government claims or judgments, this comprehensive form mandates detailed financial disclosures. It encompasses personal information, employment and business specifics, income from various sources, banking and investment details, assets ownership, credit lines, and even potential future changes in finances. The authority for requesting this information stems from various U.S. codes and regulations, underlining the government's legal basis for such financial scrutiny. The purpose behind gathering this exhaustive array of data is not only to evaluate the current financial standing of the debtor but also to forecast their capability to meet financial obligations. The form itself is designed to facilitate a clear understanding of the debtor's economic situation, with sections dedicated to accounting for each facet of their financial life, from the most basic personal data to complex asset declarations. Moreover, specific instructions for supplementary documentation, such as proof of income and statements of accounts, underscore the thoroughness with which these financial disclosures are examined. Completing this form accurately and comprehensively is crucial for those aiming to negotiate or fulfill their financial responsibilities to the U.S. government, making it a pivotal step in the process of resolving outstanding claims.

Question	Answer
Form Name	Us Dept Of Justice Financial Statement Form
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	justice statement form, department of justice financial statement of debtor, us statement debtor, financial statement of debtor get

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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

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_______________________________

Married

Separated

How long at this residence?

___________________

Unmarried (single, divorced, widowed)

____________________________________________________________________________________________

Your Social Security No. (SSN)

___________________

3a.

Your Date of Birth (mm/dd/yy)______________

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.

ＯATTACHMENTS 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______________________________

ＯATTACHMENTS 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

Other

Income

Information

10. Do you receive income from sources other than your own business or your employer? (Check all that apply.)

G	Pension	G	Social Security	G	Other (specify, e.g. child support, alimony, rental)_______________

ＯATTACHMENTS 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			$
	____________________________________________________________________________________________
	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

ＯATTACHMENTS 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
	Name of Company	Shares/Units		Value	Amount (if any)
13a.	__________________________	____________	$____________		$___________
13b.	__________________________	____________	$____________		$___________
13c.	__________________________	____________	$____________		$___________

Used as collateral on loan?

G No	G Yes
G No	G Yes
G No	G Yes

13d. Total Investments

__________________________________________________________________________________________________________

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
	____________________________________________________________________________________________
	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

ＯATTACHMENTS 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 $__________________

Purchase Date

Name of Lender

*Current Value

Monthly Payment

Description

(year, make, model)

18. PURCHASED AUTOMOBILES, TRUCKS AND OTHER LICENSED ASSETS. Include boats, RV’s, motorcycles, trailers, etc. (If you need additional space, attach a separate sheet.)

Current

Loan

Balance

Name_____________________________________SSN______________________ Page 4

__________________________________________________________________________________________

Section 7

Assets and

Liabilities

*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.	____________________		_____________________	__________	$________
	____________________
	_____________________

ＯATTACHMENTS 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

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

ＯATTACHMENTS 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.

1Expenses 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.

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Us Dept Of Justice Financial Statement Form – Fill Out and Use This PDF

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