HUD-56142 Debt Resolution Program Financial Statement

OMB Approval No. 2502-0483
(exp. 11/30/2022)

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

Debt Resolution Program
Financial Statement

Public Reporting Burden and Privacy Act Statements on Page 2 should be fully reviewed 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

Ages of Dependents

No. of Dependents

1. Employment: Employer's Name & Address

2. Pensions
Civil Service
$

Position
Other members of family employed

Per

Salary
$

Per

Social Security
$

Per

Income
$

Per

Other
$

Per

$

Per

3. Monthly Household Expenses
Rent
$

Food
$

Electricity
$

Gas
$

Rent
4. Assets
$
Cash (on hand and in banks)
Name and address of Bank where account is carried

Heat
$

Telephone
$

Other
$

Total HSHD. Expenses
$

5. Debts
$

Bills owed (grocery, doctor, utilities, etc.)
Installment accounts payable (itemize under Schedule A)

$
$

$

Notes payable (itemize under Schedule B)

$

$

Other debts (list)

$

$

Furniture, car, etc.

$

$

U.S. Saving Bonds

$

$

Other Securities

$

$

Other Assets (list below)

Electricity
$
6. Schedule A: Installment Accounts: To Whom Owed

$
$

$

$

$

$

$

(Include FHA Loans)

Amount of Original Present Balance
Debt

Payments Delinquent Monthly Payments

$

$
$
$
$

$
$
$
$

$
$
$

7. Schedule B: Notes Payable: To Whom Owed

8. Life Insurance: Name of Company

$
$
$
Total $

Amount of Original Debt
$
$

Monthly Payment
$
$

Present Balance
$
$

$
$

$
$

$
$

Face Amount of
Policy
$

Beneficiary

Annual Premium

$

$

$
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$

Cash Surrender Value

$

Amt. Borrowed on
Policy
$

$

$

$

$

form HUD-56142

9. Real Estate Owned*

Address

Type (house, business bldg., etc.)

Name & Address of Mortgage

Holder

Original Amount of
Mortgage

Present Balance

$

$

Present occupant

Interest Rate

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

In Whose Name is Title?

$

If rented, amount being paid
$

Fire Insurance Carried

Amount of Payment

To whom is rent paid

Are mortgage payments current?

Per
Date of Expiration

If delinquent, how
much?
$

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.

I/We, the undersigned, certify under penalty of perjury that the information provided above is true, correct, and accurate. WARNING: Anyone who knowingly
submits a false claim, or makes false statements is subject to criminal and civil penalties, including confinement for up to 5 years, fines, and civil penalties.
(18 U.S.C. §§ 287, 1001 and 31 U.S.C. §3729)
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 instr
uctions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. C
omments concerning the accuracy of this burden estimate and any suggestions for reducing this burden should be sent to the Reports
Management Officer, QDAM, Department of Housing and Urban Development, 451 7th St, SW, Rm 4176, Washington, DC 20410-5000. This agency may
not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection 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) justifi
cation for a compromise. Failure to collect the information would result in uneducated decisions in respect to the handling of debtor accounts. The Federal Cla
im Collection Standards states: If the agency’s files do not contain reasonably up-to-date credit information as a basis for assessing a compromis
e, such information may be obtained from the individual debtor by obtaining a statement executed under penalty of perjury showing the debtor’s assets and lia
bilities, 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:
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of the following concerning the collection of the information on this form.
Authority: The Debt Collection Improvement Act of 1996 (Pub. L. 104-134, 5 U.S.C. 5514, 31 U.S.C. 3701 et seq.), as amended; The Federal Claims
Collection Act of 1966 (Pub. L. 89-508) and Debt Collection Act of 1982 (Pub. L. 97-365); 31 C.F.R. 285; 24 C.F.R. Part 17, Subpart C; 80 Stat. 309,
Section 3(b); The Housing and Community Act of 1987, 42 U.S.C. 3543(a), authorizes HUD to collect the Social Security Number (SSN); 12 U.S.C.
1703(c) authorizes the collection, compromise, and sale of debt obligations to HUD in connection with the payment of FHA loans.
Purpose: HUD’s mission is to provide effective and efficient servicing to maximize the recovery of debts and minimize losses arising from FHA loan
programs. The purpose for collecting this information is to support activities related to the collection of debts resulting from defaults on HUD/FHA insured Title I
loans and from other HUD/FHA loans.
Routine Use: The information collected on this form will be used by HUD to collect this debt and assess your ability to repay. Information will not be
otherwise disclosed or released outside of HUD, except as permitted or required by law to appropriate Federal, state, and local agencies when relevant to debt
collection, payment offsets, and reporting; to civil, criminal, or regulatory investigations and/or prosecutions; to your employer to issue wage
garnishment order; to third party debt purchasers for relevant asset sale transactions; to appropriate agencies, entities, and persons to mitigate a breach or rel
ated incident. Information may also be used by HUD for computer matching for verification purpose.
Disclosure: Completion of this form is voluntary and not required. You may object to this information request by refusing to complete the form. You may
withhold your consent to specific uses of your information by withholding that information. However, the information requested is required to obtain
benefits.
SORN URL: https://www.govinfo.gov/content/pkg/FR-2007-11-13/pdf/E7-22077.pdf

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form HUD-56142