HUD-56142 Debt Resolution Program Financial Statement

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

Debt Resolution Program
Financial Statement

OMB Approval No. 2502-0483
(Exp. 12/31/2009)

See the Public Reporting Burden and Privacy Act
statements on the back before completing this form
To: U.S. Department of Housing and Urban Development
Debt Management Center

FHA Claim Number
Date

For the purpose of inducing you to give favorable consideration to my (our) circumstances, I (we) submit the following information to you by U.S. Mail. I (we)
certify that the information exactly and fully reflects my (our) financial status—assets, liabilities, income and expenses, as of the date the statement is executed.
Name(s) & Address

Age

No. of
Dependents

Ages of Dependents

1. Employment: Employer's Name & Address

2. Pensions
Civil Service

$

Position

Salary

Social Security

$

Other members of family employed

$

Per

Per

$

Per

$

Per

$

Per

Income

Per

Other

3. Monthly Household Expenses
Rent
Food

Electricity

Gas

Heat

Telephone

Other

Total HSHD. Expenses

$

$

$

$

$

$

$

$

4. Assets

Cash (on hand and in banks)
Name and address of Bank where account is carried
__________________________________________
__________________________________________
__________________________________________
Furniture, car, etc.
U.S. Saving Bonds
Other Securities
Other Assets (list below)
__________________________________________
__________________________________________
__________________________________________
6. Schedule A: Installment Accounts: To Whom Owed

5. Debts
Bills owed (grocery, doctor, utilities, etc.)
$ ______________
Installment accounts payable (itemize under ScheduleA) $ ______________
Notes payable (itemize under Schedule B)
$ ______________
Other debts (list)
__________________________________________
$ ______________
__________________________________________
$ ______________
__________________________________________
$ ______________
__________________________________________
$ ______________
__________________________________________
$ ______________
__________________________________________
$ ______________
__________________________________________
$ ______________
__________________________________________
$ ______________

$ ______________
$ ______________
$ ______________
$ ______________
$ ______________
$ ______________
$ ______________
$ ______________
$ ______________
$ ______________
(Include FHA Loans)

Amount of Original
Debt

Present Balance

Payments Delinquent Monthly Payments

$
$
$
$

$
$
$
$

$
$
$
$

$
$
$
$
$

Amount of Original
Debt

Monthly Payment

Present Balance

$
$
$
$

$
$
$
$

$
$
$
$

Total
7. Schedule B: Notes Payable: To Whom Owed

8. Life Insurance: Name of Company

Face Amount of
Policy

Beneficiary

Annual Premium

Amt. Borrowed on
Policy

Cash Surrender Value

$
$

$
$

$
$

$
$

$
$

Page 1 of 2

ref Handbook 4740.2

form HUD-56142 (1/2006)

9. Real Estate Owned*

Address

Type (house, business bldg., etc.)

Name & Address of Mortgage Holder

Original Amount of
Mortgage

Present Balance

Interest Rate

Terms of Payment
Amount of Payment
(monthly, quarterly, etc.)

$

$

$

$

Present occupant

If rented, amount being paid

$
Fire insurance carried

In Whose Name is Title?

$
To whom is rent paid

Are mortgage payments current?

Per

If delinquent, how
much?

$

Date of Expiration

Loss payable to

$
Annual taxes

Taxes paid to date

$

$

*

If delinquent, indicate years and amounts

I value this property at

$

If you own more property, answer on a separate sheet the questions listed above for each parcel.

Under penalties of perjury, I (we) affirm that the foregoing information is true, correct and complete to the best of my (our) knowledge and ability.
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)
Social Security Number

Signature

Date

Social Security Number

Signature

Date

Public reporting burden for this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collecton displays a valid OMB control
number.
This information is used by HUD to evaluate: (a) the debtor’s ability to pay the debt in full; (b) the ability to pay the debt in installments; and/or (c) justification
for a compromise. Failure to collect the information would result in uneducated decisions in respect to the handling of debtor accounts. The Federal Claim
Collection Standards states: If the agency’s files do not contain reasonably up-to-date credit information as a basis for assessing a compromise, such
information may be obtain from the individual debtor by obtaining a statement executed under penalty of perjury showing the debtor’s assets and liabilities,
income and expenses. The information is used to evaluate the individual debtor’s financial position for the purpose of establishing payment plans and/
or compromise settlements. This information is voluntary. The debtors are protected by the Privacy Act of 1974.
Privacy Act Statement: The Department of Housing and Urban Development (HUD) is authorized to collect all the requested information by 80 Stat.309,
Section 3(b). The Housing and Community Development Act of 1987, 42 U.S.C. 3543 authorizes HUD to collect the Social Security Number (SSN). It
will be used as a basis for assessing your ability to repay this debt. This information will not be otherwise disclosed or released outside of HUD, except
as permitted or required by law or to appropriate Federal, state and local agencies, and when relevant to civil, criminal or regulatory investigations and/
or prosecutions. The provision of the SSN is mandatory. Failure to provide some or all of the information may result in legal action to collect the debt.
Completion of this form is not required. However, the information requested is required to obtain benefits. Please fill out this form or provide the information
in another format.
Page 2 of 2

ref Handbook 4740.2

form HUD-56142 (1/2006)