Information Collection

Financial Status Report

IC 44123 under ICR 201501-2900-004 · OMB 2900-0165.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0165 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5655 Financial Status Report	Form
5655 Financial Status Report VA5655.pdf www1.va.gov/debtman	Form

IC Title:

Financial Status Report

Agency IC Tracking Number:

2900-0165

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 1.917 38 CFR 1.931 38 CFR 1.941 38 CFR 1.942 38 CFR 1.965 38 CFR 1.912 38 CFR 1.982 38 CFR 1.983

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	5655	Financial Status Report	VA5655.pdf	http://www1.va.gov/debtman	Yes	No	Fillable Fileable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 95,570

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	95,570	38,415	57,155
Annual IC Time Burden (Hours)	95,570	38,415	57,155
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.