Form FF 22-13 FF 22-13 Debt Collection Financial Statement

See reverse side for
Paperwork Burden
Notice

U.S. DEPARTMENT OF HOMELAND SECURITY FEDERAL
EMERGENCY MANAGEMENT AGENCY

DEBT COLLECTION FINANCIAL STATEMENT

O.M.B. No. 1660-0011
Expires April 30, 2008

PRIVACY ACT STATEMENT
This information is provided to Public Law 93-579 (Privacy Act of 1974), December 31, 1974. Authority for solicitation of the requested information
is 31 U.S.C. 3711 et seq. Debt Collection Act of 1982, Public Law 97-365 and Debt Collection Improvement Act of 1996, Public Law 104-134. The
principal purpose for gathering this information is to evaluate your ability to pay the government's claim or judgement against you. Disclosure of
the information is voluntary. If the requested information is not furnished, the Federal Emergency Management Agency has the right to such
disclosure of the information by legal methods.
Solicitation of the Social Security Number (SSN) is authorized under the provisions of 31 U.S.C. 7701. The SSN is needed to facilitate the collection
of delinquent debt. Pursuant to 31 U.S.C. 3711 FEMA is required to transfer delinquent debts over 180 days old to the Department of the Treasury
(Treasury) for collection. Once the debt is submitted to Treasury for collection, the debtor's name and SSN will be subject to computer matching
with sources of payments that may be due the debtor. Treasury will reduce or withhold any of debtor's eligible Federal payments by the amount
debt. Treasury may also refer the debt to the Department of Justice, a private debt collection agency, and report debtor information to a
of the
consumer credit reporting agency.
NAME OF DEBTOR
DATE OF BIRTH

NAME OF SPOUSE
HOME PHONE

SOCIAL SECURITY NUMBER

DATE OF BIRTH

COMPLETE ADDRESS (Including zip code and county)

MARITAL STATUS

NO. OF CHILDREN
(give age(s))

SOCIAL SECURITY NUMBER

COMPLETE ADDRESS (Including zip code - Complete if different from spouse)

NO. OF DEPENDENTS (Other
than children)

NAME OF EMPLOYER

NAME OF EMPLOYER

ADDRESS

ADDRESS

POSITION (Give No. of years there)

POSITION (Give No. of years there)

GROSS INCOME (Hr., Mo., yr.) $

OTHER INCOME (Source)

INCOME (Mo.)
$

HOUSING
RENT BY MO.
OWN (Title in Name of):

OTHER INCOME (Source)

MO. PYMT. or RENT

YR. PUR.

NO

$

YES
AMT. OWNED

$

INCOME (Mo.)
$

COST

$
DO YOU OWN ANY REAL ESTATE?
Address (Include county)

GROSS INCOME (Hr., Mo., yr.) $

MKT. VALUE

AMT. MORTGAGE

$

$
DO YOU OWN ANY STOCK OR BONDS?
NO
YES (Value)
$

MO. PYMT.
$

$

MKT. VALUE

AMT. OWED

CAR(S) OWNED (Make, Model & Year)

MO. PAYMENT

$
$

HOW DO YOU PROPOSE TO PAY YOUR DEBT TO THE UNITED STATES?

NAME OF BANK(S) (Include Address and account number)
CHECKING
SAVINGS

- AVG BALANCE

$
$

I WILL PAY:

$
$

per Mo. beginning

,20

I WILL PAY:

- BALANCE $

on

a Lump Sum of $
NAME OF CREDITORS (Use reverse side if more space is needed)
1.
2.
3.

AMT. OWED

,20

MO. PAYMENT

AMT. PAST DUE

$

$

$

$

$

$

$

$

$
WARNING

Title 18, Sec. 1001 U.S. Code: "Whoever knowingly and willfully falsified, conceals or covers up by any trick, scheme, or device a material fact, or makes any false,
fictitious statements or representations, shall be fined not more than $10,000 or imprisoned not more than five years, or both."
I Declare Under the Penalties Provided for by Title 18, Section 1001 of the U.S. Code that all Answers and Statements Contained Herein Are to the Best of
my
Knowledge
and Belief, True, Correct, and
Complete.

Date

Signature
FEMA Form 22-13, JUN 05

REPLACES ALL PREVIOUS EDITIONS.

PAPERWORK BURDEN DISCLOSURE NOTICE

"Public reporting burden for this form is estimated to average 45 minutes per response. The burden estimate
includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and submitting the form. You are not required to respond to this collection of information
unless it displays a valid O.M.B. control number Send comments regarding the accuracy of the burden estimate or any
suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security,
Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project
(1660-0011). Pleas do not send your completed form to this address.