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OMB No. 0938-0270
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
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 reverse side of pages.)
Authority for the solicitation of the requested information is one or more of the following: 42 CFR 405.376; 4 CFR 101, et.seq.; 31 U.S.C. 951,
et seq.
The principal purpose for gathering this information is to evaluate your capacity to pay the Government’s claim against you. Disclosure of the
information is voluntary. If the requested information is not furnished, the Government will pursue immediate and full payment of its claim
against you.
1. Name (debtor)
2. Birth Date (mo., day, yr.)
3. Home Address
4. Phone No.
5. Name of Spouse (give address if different from yours)
6. Date of Birth (mo., day, yr.)
Debtor Employment Data
7. Occupation
8. How Long in Present Employment?
9. Present Employer’s Name
Address
Phone No.
10. Other Employment—Within Last 3 Years
Employer’s Name
Address
Phone No.
Employment
Dates
11. Present Monthly Income
Salary or Wages $
Other (state source) $
Commissions $
Total $
Spouse’s Employment Data
12. Occupation
13. How Long in Present Employment?
14. Spouse’s Present Employer’s Name Address
Phone No.
15. Other Employment—Within Last 3 Years
Employer’s Name
Address
Phone No.
Employment
Dates
16. Present Monthly Income
Commissions $
Salary or Wages $
Other (state source) $
Total $
Dependents
17. Total
Number
Relationship
Age
Relationship
Age
Relationship
Age
18. Total Monthly Income of
Dependents (except spouse)
$ _________________________________
Form CMS-379 (07/07) EF 07/2007
Page 1 of 4
Financial Data
19. For What Period Did You Last
File a Federal Income Tax Return
20. Where Filed
21. Amount of Gross Income
Reported
22. Fixed Monthly Expenses
Rent
Food
Utilities
Debt Repayments (Including installments)
Other (specify)
Interest
Total Fixed Monthly Charges
23. Loans Payable
Owed To
Original
Amount
Purpose & Date of Loan
Present
Balance
24. Assets and Liabilities
(Fair market value)
Assets
Cash
$ ___________________
Checking Accounts (show location)
________________________________________
________________________________________
___________________
___________________
Savings Accounts (show location)
________________________________________
________________________________________
___________________
___________________
Motor Vehicles
Year
Make/License No.
________________________________________
________________________________________
___________________
___________________
Debts Owed to You (give name of debtor)
________________________________________
________________________________________
___________________
___________________
Bills Owed (grocery, doctor, lawyer, etc.)
$ ___________________
Installment Debt (car, furniture, clothing, etc.)
___________________
Taxes Owed
___________________
Income
Other (itemize)
___________________________
___________________________
___________________
___________________
Loans Payable (to banks, finance company, etc.) ___________________
Judgments You Owe
___________________
Real Estate Mortgages
____________
Other Debts (itemize)
Judgments Owed to You
___________________________
___________________________
___________________
___________________
Stocks, Bonds and Other Securities (itemize)
___________________________
___________________________
___________________________
___________________________
___________________
___________________
___________________
___________________
Household Furniture and Goods
Items Used In Trade or Business
Other Personal Property (itemize)
___________________________
___________________________
___________________
___________________
Real Estate
___________________________
___________________________
___________________________
___________________
___________________
___________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
Total Assets $ _________________
_________________
Form CMS-379 (07/07) EF 07/2007
Liabilities
_________________
Total Liabilities $ _________________
Page 2 of 4
25. Real Estate Owned
Address
How Owned (jointly,
individually, etc.)
Date
Acquired
Cost
Unpaid Amount
of Mortgage
26. Real Estate Being Purchased Under Contract
Name of Seller
Address
Contract Price
Principal Amount Still Owing Next Cash Payment Due (date)
Amount (of next payment due)
27. Life Insurance Policies
Company
Face Amount
Cash Surrender Value
Outstanding Loans
28. All Real and Personal Property Owned by Spouse and Dependents Valued in Excess of $200 (List each item separately)
29. All Transfers of Property Including Cash (by loan, gift, sale, etc.) That You Have Made Within the Last 3 Years (items of $300 or over)
Date
Amount
Property Transferred
To Whom
30. Are you a party in any lawsuit now pending?
■ Yes, give details below
■ No
31. Are you a trustee, executor, or administrator?
■ Yes, give details below
■ No
32. Is anyone holding any moneys on your behalf?
■ Yes, give details below
■ No
Form CMS-379 (07/07) EF 07/2007
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33. Is there any likelihood you will receive an inheritance?
■ Yes, from whom?
■ No
34. Do you receive, or under any circumstances, expect to receive benefits, from any established trust, from a claim for compensation or
damages, or from a contingent or future interest in property of any kind?
■ Yes, explain below
■ No
With knowledge of the penalties for false statements provided by 18 United States Code 1001 ($10,000 fine and/or 5 years imprisonment) and
with knowledge that this financial statement is submitted by me to affect action by the Department of Health and Human Services, 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
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0270. The time required to complete this information collection is estimated to
average 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Form CMS-379 (07/07) EF 07/2007
Page 4 of 4
File Type | application/pdf |
File Title | CMS-379.qxd |
File Modified | 2007-07-24 |
File Created | 2007-07-24 |