Form Cms-379 - Financial Statement Of Debtor Page 2
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4Financial Data
19. For What Period Did You Last
20. Where Filed
21. Amount of Gross Income
File a Federal Income Tax Return
Reported
22. Fixed Monthly Expenses
Rent
Food
Utilities
Interest
Debt Repayments (Including installments)
Other (specify)
Total Fixed Monthly Charges
23. Loans Payable
Original
Present
Owed To
Purpose & Date of Loan
Amount
Balance
24. Assets and Liabilities
Assets
(Fair market value)
Liabilities
Cash
$
Bills Owed (grocery, doctor, lawyer, etc.)
$
Checking Accounts (show location)
Installment Debt (car, furniture, clothing, etc.)
Taxes Owed
Income
Savings Accounts (show location)
Other (itemize)
Motor Vehicles
Year
Make/License No.
Loans Payable (to banks, finance company, etc.)
Judgments You Owe
Debts Owed to You (give name of debtor)
Real Estate Mortgages
Other Debts (itemize)
Judgments Owed to You
Stocks, Bonds and Other Securities (itemize)
Household Furniture and Goods
Items Used In Trade or Business
Other Personal Property (itemize)
Real Estate
Total Assets $
Total Liabilities $
Form CMS-379 (07/07) EF 07/2007
Page 2 of 4
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Parent category: Medical