VA Form 5655

Enter your Social Security No. in box 1 and your File No. in box 2.

In box 3, specify why you are completing this form: Waiver, Compromise, Payment Plan or Other.

In box 4, enter the First-Middle-Last Name of Person, and in box 5 the Address (Number and street or rural route, City or P.O. Box, State, and ZIP Code).

Enter the Telephone No. (Include Area Code) in box 6 and the Date of Birth (MM-DD-YYYY) in box 7. For box 8, Marital Status, mark Married or Not Married.

Enter the Name of Spouse in box 9 and the Age(s) of Other Dependents in box 10.

Complete the record of employment for yourself and spouse during past 2 years.

For each job, enter the Dates (MM-YYYY) From and To, the Kind of Job and the Name and Address of Employer.

Box 11 is Your Employment Experience and box 12 is Your Spouse's Employment.

Section II - Income, Average Monthly Income, has Self and Spouse.

Enter the Monthly Gross Salary (Before payroll deductions) in box 13.

In box 14, Payroll Deductions, enter A. Federal, State and Local Income Taxes, B. Retirement, C. Social Security and D. Other (Specify).

Enter the Total Deductions (boxes 14A through 14D) in box 14E.

For box 15, Net Take Home Pay, subtract box 14E from box 13.

In box 16, VA Benefits, Social Security, or Other Income, specify the source.

For box 17, Total Monthly Net Income, add box 15 plus box 16.

Section III - Expenses: Average Monthly Expenses.

Enter the Rent or Mortgage Payment in box 18.

Enter Food in box 19, Utilities and Heat in box 20 and Other Living Expenses in box 21.

In box 22, Monthly Payments on Installment Contracts and Other Debts, include amount from Section VI, Line 34I - Column E.

Enter the Total Monthly Expenses in box 23.

In Section IV - Discretionary Income, box 24A is Net Monthly Income Less Expenses (box 17 less box 23).

Enter the Amount You Can Pay on a Monthly Basis Toward Your Debt in box 24B.

Section V - Assets: in box 25, enter the Cash in Bank (Checking and savings accounts, building and loan accounts, etc.).

Enter the Cash on Hand in box 26.

For box 27, Automobiles (Resale value), enter the Make, Year and Model and the Resale value.

Enter the Trailers, Boats, Campers (Resale value) in box 28.

Enter U.S. Savings Bonds (Current Value) in box 29, Stocks and Other Bonds (Current Value) in box 30 and Real Estate Owned (Resale value) in box 31.

In box 32, Other Assets, specify below.

Enter the Total Assets in box 33.

Show ALL debts which you are required to pay in regular monthly installments, such as a car, television, washing machine, payments to dealers, banks, finance companies, repayment of money borrowed for any purpose, doctor bills, hospital bills, etc. DO NOT INCLUDE LIVING EXPENSES.

For each debt, enter the Name and Address of Creditor, the Date and Purpose of Debt, the Original Amount of Debt, the Unpaid Balance, the Amount Due Monthly and the Amount Past Due (If any).

Enter the Total on line 34I.

If repayment of a debt is not on a monthly basis, write "0" in column E and describe arrangements to repay in box 36.

In box 35A, mark YES or NO to Have you ever been adjudicated bankrupt? If so and VA or a mortgage company was involved, please send all pertinent documentation. If "Yes," complete boxes 35B through 35D.

Enter the Date Discharged from Bankruptcy (MM-DD-YYYY) in box 35B, the Location of Court in box 35C and the Docket No. (If known) in box 35D.

In box 36, use this space and additional sheets, if necessary, to supply any pertinent information and to continue your answer to previous item number(s) to which your comments apply.

The Financial Status Report: specify why you are completing this form (Waiver, Compromise, Payment Plan or Other). Type or print all entries. If more space is needed for any item, continue under Section VII, Additional Data, box 36 or attach separate sheet.

37A. Your Signature (Required) and 38A. Signature of Spouse (Required), each with its Date Signed, 37B and 38B.

The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact, knowing it to be false.