Form FEMA Form 127-0-1 FEMA Form 127-0-1 Debt Collection Financial Statement

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

See reverse side for
Paperwork Burden
Notice

DEBT COLLECTION FINANCIAL STATEMENT

O.M.B. No. 1660-0011
Expires March 31, 2011

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
these forms. You are not required to respond to this collection of information unless a currently valid OMB control number and
expiration date is displayed in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and
suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency
Management Agency, 500 C Street, S.W., Washington, DC 20472, Paperwork Reduction Project (1660-0011). NOTE: Do not send
your completed form to this address.
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

NAME OF DEBTOR

NAME OF SPOUSE

DATE OF BIRTH

HOME PHONE

SOCIAL SECURITY NUMBER

COMPLETE ADDRESS (Including zip code and county)

MARITAL STATUS

DATE OF BIRTH

SOCIAL SECURITY NUMBER

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

NUMBER OF CHILDREN NUMBER OF DEPENDANTS
(give age (s))

(other than children)

NAME OF EMPLOYER

NAME OF EMPLOYER

ADDRESS

ADDRESS

POSITION (No. of years there)

SALARY (Hr.,Mo., yr.)

OTHER INCOME (Source)

$
OTHER INCOME (Mo.)

SALARY (Hr.,Mo., yr.)

POSITION (No. of years there)

$
OTHER INCOME (Mo.)

OTHER INCOME (Source)

$

$

HOUSING

RENT BY MONTH

OWN (Title in Name of):

MO. PYMT. or RENT $

YR. PUR.

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

COST $

NO

MKT. VALUE $

MKT. VALUE $

YES

DO YOU OWN ANY STOCK OR BONDS?

$

$

$

$

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

$

$

per month beginning

20,

on

20,

I WILL PAY:
a Lump Sum of $

$

NAME OF CREDITORS (Use reverse side if more space is needed)

AMOUNT OWED

1.
2.
3.
FEMA Form 127-0-1, MAY 10

$

MO. PYMT

AMT. OWNED

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

SAVINGS - BALANCE

YES (Value)

NO

MO. PYMT. $

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

CHECKING - AVG BALANCE

AMT. MORTGAGE $

PREVIOUSLY FEMA Form 22-13

MONTHLY PAYMENT

AMOUNT PAST DUE

PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301; The Federal Records Act, 44 U.S.C. 3101; The Homeland Security Act of 2002, Public Law 107-296,
6 U.S.C. 121; Public Law 89-508; Federal Claims Collection Act of 1966, 31. U.S.C. 3701; and Executive Order 9373. Solicitation
of the Social Security Number (SSN) is authorized under the provisions of 31 U.S.C 7701.
PRINCIPAL PURPOSE(S): This information is to evaluate debtor's ability to pay the government's claim or judgement.
ROUTINE USE(S): In general, DHS/FEMA will only use this information as stated above. DHS/FEMA may share this information
on a case-by-case basis as required by law or as necessary for a specific purpose, as described in the routine uses found in the
Accounts Receivable System of Records Notice, DHS/ALL-008, (October 17, 2008, 73 FR 61885). Pursuant to 31 U.S.C 3711,
the Federal Emergency Management Agency (FEMA) is required to transfer delinquent debts over 180 days old to the
Department of the Treasury (Treasury) for collection. When the debt is submitted for collection, the debtor's name and SSN will
be shared with Treasury with sources of payments that may be due the debtor. Treasury will reduce or withhold any of the
debtor's eligible Federal payments by the amount of the debt. Treasury may also refer the debt to the Department of Justice, a
private debt collection agency, and/or report debtor information to a consumer credit reporting agency.
DISCLOSURE: The disclosure of information on this form is voluntary. If the requested information is not furnished, FEMA has
the right to such disclosure of the information by legal methods.