FS Form 00123 Financial Statement of Debtor

FS Form 000123
OMB No. 1530-XXXX

Financial Statement of Debtor
(Submitted for Government Action on Claims Due the United States)

Instructions:

1) Complete all blocks. Write “N/A” in blocks that do not apply.
2) Use additional sheets or back of page where space is insufficient.
3) Must provide with this financial statement:
a. last two pay stubs
b. last tax return
c. proof of major expenses listed in “Fixed Monthly Expenses”
4) Submit documentation to E-mail: [email protected]
or Mail: Bureau of the Fiscal Service - ARS, PO Box 7010, Parkersburg, WV 26106

Privacy Act Notice: We are asking you for this information pursuant to the U. S. Department of the Treasury's
authority to collect debts owed to the United States, which is found at 31 U.S.C. 321, 3701 et seq., and 31 C.F.R.
parts 285 and parts 900-904. The principal purpose for gathering this information is to evaluate your ability to pay
the Government's claim or judgment against you. This information may be disclosed to other Federal agencies,
credit bureaus, and private collection agencies for the purpose of collecting debt(s) owed by you to the United
States. Your name and social security number may be disclosed to your employer if we decide to garnish your
wages to collect debt(s) owed by you to the United States. This information may also be disclosed to a court,
magistrate, congressional office, or a Federal, state, or local government agency, as authorized or required by
Federal law. We are required to ask you for your social security number pursuant to 31 U.S.C. 7701(c)(1). Your
social security number will be used for purposes of collecting and reporting on any delinquent amounts you owe to
the United States. Disclosure of your financial information is voluntary. However, if the requested information is not
furnished, the U.S. Department of the Treasury may not be able to resolve your debt pursuant to a mutual
agreement, and we may ask the Department of Justice to obtain disclosure of the information by legal methods.

A. Personal Identification
Name (Debtor):

Birth Date (M/D/Y):
Home Address

Street 1:
Street 2:

Social Security Number:

Driver’s License Number and State:
Home Phone:

City:
State:

Email:

Zip Code:

B. Employment
Present Employer’s Name:

Employer’s Phone Number:

Employer’s Address
Street 1:

Job Title:

Street 2:
City:
State:

Present Employment Length:

Zip Code:
List other current employers and any you have had in the last 3 years:

Ext:

C. Monthly Income and Expenses
•
•

Must attach a copy of last two paystubs and proof of major expenses
Additional documentation may be requested if expenses or income fall outside expected amounts

INCOME
Gross Salary1 (Before Deductions) Monthly
Gross Salary2 (Before Deductions) Monthly
OTHER INCOME SOURCES

Commission
Monthly
Alimony Received
Monthly
Child Support Received
Monthly
Net Rental Income
Monthly
Interest/dividends
Monthly
Personal Income from Business Monthly
Monthly
Pension income
Monthly
Insurance annuity
Monthly
Disability or SSI
Unemployment
Monthly
Other Income:

Deductions
(Deductions per time period on paystub or documents)

Federal Taxes
State/County/City Taxes
Social Security Taxes (FICA/Medicare)
Medical Insurance
Union Dues (If applicable)
Life Insurance
Allotments to Bank or Fin. Institutions
Other payroll deductions (401k)
Total Monthly Take home pay
(Gross Salary + Other Income – Deductions)

EXPENSES
---all expenses should be calculated as monthly-Rent/Mortgage
Home Hazard Insurance
Local Home Taxes (if paid separately from mortgage)
Childcare (Daycare)
Car Payment
Car Insurance
Public Transportation
Gasoline
Electricity
Cable TV
Internet
Telephone (Landline + Cell)
Natural Gas
Water
Trash
Other Utilities (Specify)
Food
Clothing
Child support paid
Alimony paid
Student Loan/s
Medical expenses (out-of-pocket)
Credit Card/s (min. amount due)
Other (Specify)
Other (Specify)
Total Monthly Expenses
(Sum of all of above)

D. SPOUSE/COMPANION
•
•
•

By providing this information, you are not indicating spouse liability for invoice
Spouse information is voluntary, however if bills listed in spouse name, their income is required.
If not married but have a live-in companion, you may choose to furnish information on this companion below.

Current Spouse’s Name:

Birth Date (mm/dd/yy):

If spouse’s home address is different, list:
Employer Name:

Employer Phone:

Employment length:

Job Title:

Gross salary: $

Take home pay: $

E. DEPENDENTS
Name

Age

Relationship

F. TAXES
•

Must attach a copy of your last filed Federal income tax form
☐ Yes

Did you file a Federal Income Tax Return last year?
If Yes, ☐ Joint ☐ Individual

☐ No

Amount of Gross Income on return was $

Are you or did you receive a tax refund from Federal, State, City or County? ☐ Yes ☐ No
If yes, list from whom and amount for each refund:
Entity:
$
Entity:
$
Entity:
$
Entity:
$
Do you owe delinquent taxes?
☐ Yes ☐ No If yes, list below, years and amounts due:
Entity:
Year:
Amount Due: $
Entity:
Year:
Amount Due: $

G. ASSETS
REAL PROPERTY: FARM/LAND/VACATION HOME/RENTAL
Are you buying the home in which you live?

☐ Yes

☐ No

Are you buying or do you own real property other than your home? ☐ Yes
Property Description

☐ No
Value

Equity

Is any of the above property owned jointly another? ☐ Yes ☐ No If yes, list property and the name of the co-owner:
Property:
Co-Owner:
Property:
Co-Owner:

CASH
Provide name of the bank or financial institution, and the amount in each account or on deposit:
Name of Bank or Institution
Balance
Name of Bank or Institution
Check Account $
Money Market Account $
Certificate of Deposit $
Savings Account $
IRA or Keogh Account $
Credit Union Account $

Balance

OTHER ASSETS
☐ Yes

Do you or your spouse/companion own U. S. Savings Bonds?

☐ No

Value: $

☐ No
If yes, list details below
Address of Issuer
$
$
List automobiles owned or being purchased by you, your spouse/companion or dependent:
Model/Year
Make/License Number
$
$
$
$
List other assets by Type:
Value: $
Antiques, art collection
Value:
Camper/Recreational Vehicle
Jewelry valued over $5,000
Value:
Boat, Motorcycle, or Motorbike Value: $

Do you own stocks or other types of bonds?
Name of Issuer

☐ Yes

Is any of the property listed above owned jointly with anyone else?
If yes, with whom:

☐ Yes

Value

Value

$
$

☐ No

H. ITEMS WHICH MIGHT AFFECT FUTURE ASSETS:
Are you involved in a lawsuit in which you might receive money or something of value: ☐ Yes
If yes, state where the suit is filed and what it involves (include Court number and caption):
Are you a Trustee, Executor, or Administrator of an estate?
If yes, give details:
If anyone holding money on your behalf?
If yes, give specific details:

☐ Yes

☐ Yes

☐ No

☐ No

☐ No

If there any likelihood you will receive an inheritance?
☐ Yes ☐ No
If yes, give specific details:
Have you sold or transferred either real property or stocks and bonds in the past three years?
If yes, give specific details:
Are your wages and/or those of your spouse/companion under garnishment at this time? ☐ Yes
If yes, give specific details:
Are there any outstanding unpaid judgments against you for debts other than this one?
If yes, give specific details and attach copies of the bills.

☐ Yes

☐ No

☐ No

☐ Yes

☐ No

Do you owe large medical bills?
☐ Yes ☐ No
If yes, give specific details and attach copies of the bills.
With knowledge of the penalties for false statements provided by 18 United State Code 1001 ($10,000 fine
and/or five years imprisonment) and with knowledge that this financial statement is submitted by me to affect
action by the U. S. Department of Treasury, I certify that I believe the above statement is true and that it is a
complete statement of all my income and assets, real and personal, whether held in my name or by any other.
Date:

Signature:

Date:

Signature:

Please Note: If you have added additional sheets to this form, or added information on the back of this page
or any page, please also sign those pages.

Notice Under the Paperwork Reduction Act:
We estimate it will take you about 45 minutes to complete this form. However, you are not required to provide information
requested unless a valid OMB control number is displayed on the form. Any comments or suggestions regarding this form
should be sent to the Bureau of the Fiscal Service, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT
SEND completed form to the above address; send to correct address shown in “Where to send” in the Instructions.