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

O.M.B. No. 1660-0011
Expires June 30, 2014

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
DEBT COLLECTION FINANCIAL STATEMENT
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. This collection of information
is voluntary. You are not required to respond to this collection of information unless a 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, SW, Washington, DC
20472-3100, Paperwork Reduction Project (1660-0011). NOTE: Do not send your completed form to this address.
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.
WARNING
Title 18, Sec. 1001 U.S. Code: "Whoever knowingly and willfully falsifies, 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.

Signature

Date

NAME OF SPOUSE

NAME OF DEBTOR
DATE OF BIRTH

DATE OF BIRTH

SOCIAL SECURITY NUMBER

HOME PHONE

COMPLETE ADDRESS (Including zip code - Complete if different from

COMPLETE ADDRESS (Including zip code and county)

MARITAL STATUS

NUMBER OF CHILDREN
(give age (s))

spouse)

NUMBER OF DEPENDANTS
(other than children)

NAME OF EMPLOYER

NAME OF EMPLOYER

ADDRESS

ADDRESS
SALARY (Hr., Mo., Yr.)

POSITION (No. of years there)

SOCIAL SECURITY NUMBER

SALARY (Hr.,Mo., Yr.)

POSITION (No. of years there)

$
OTHER INCOME (Source)

$

OTHER INCOME (Mo.)

OTHER INCOME (Source)

OTHER INCOME (Mo.)

$
HOUSING

RENT BY MONTH

MO. PYMT. or RENT $

$
OWN (Title in Name of):

YR. PUR.

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

FEMA Form 127-0-1

MKT. VALUE $

COST $

NO

MKT. VALUE $

YES
MO. PYMT. $

AMT. MORTGAGE $
DO YOU OWN ANY STOCK OR BONDS?

NO

YES (Value)

$

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DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
DEBT COLLECTION FINANCIAL STATEMENT
AMT. OWED

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

NAME OF BANK(S) (Include Address and account number)
CHECKING - AVG BALANCE

$

$

$

$

$

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

$
SAVINGS - BALANCE

$

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

MO. PYMT

per month beginning

I WILL PAY:
a Lump Sum of $
AMOUNT OWED

on
MONTHLY PAYMENT

20,
20,
AMOUNT PAST DUE

1.
2.
3.

FEMA Form 127-0-1

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