Financial Statement Of Debtor (Submitted For Government Action On Claims Due The United States)
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6U.S. Department of Justice
Financial Statement of Debtor
(Submitted for Government Action on
Claims Due the United States)
NOTE:
Use additional Sheets where space on this form
is insufficient or continue on back of last page.
Authority for the solicitation of the requested information is one or more of the following 5 U.S.C. 301. 901 (see Note, Executive Order 6166,
June 10 1953): 28 U.S.C. 501 et seq., ; 44 U.S.C. 3101:4 CFR 101, et seq.; 28 CFR 0.160.0171 and Appendix to Subpart Y.
Fed.R.Civ. P. 33(a) 28 U.S.C. 1651.3201 et seq.
The principal purpose for gathering this information is to evaluate your ability to pay the Government’s claim or judgment against you. Routine
uses of the information are established in the following U.S. Department of Justice Case File Systems published in Vol.42 of the Federal Register
Justice /CIV-001 at page 5332: Justice/TAX-001 at page 15347; Justice/USA-005 at pages 53406-53407; Justice/USA-007 at pages 53408-5310
Justice/CRIM-016- at page 12774. Disclosure of the information is voluntary. If the requested information is not furnished the U.S. Department of
Justice has the right to such disclosure of the information by legal methods.
PERSONAL IDENTIFICATION
1. Name (debtor)
2. Birth Date (mo. day. yr.)
3. Social Security No.
4. Home Address (Street)
5. Driver’s License No.
6. (City, State & Zip Code)
6a. Home Phone (Area Code)
EMPLOYMENT * *
7. Present employers’ name
8. Employer’s Phone Number
(
)
9. Employer’s Address (Street)
10. Job Title
(City State & Zip Code)
11. Present employment (Length)
12. List other employers you have had in the last 3 years:
SALARY, WAGES OR COMMISSION
13. Your gross salary ( before any deductions)
Circle One
weekly
biweekly monthly
$---------------------------------------------------
14. Your take home pay is
$---------------------------------------------------
15. Your commission is
$ --------------------------------------------------
List the amount of deductions for.
16.
Federal Taxes
$-------------------
17.
State/County/City Taxes
$-------------------
18.
Social Security Taxes (FICA/Medicare
$-------------------
19.
Total
$---------------------------------------------------
19.
Medical Insurance
$---------------------------------------------------
20.
Union Dues if applicable
$---------------------------------------------------
21.
Allotments to Credit Union, Bank or others
$---------------------------------------------------
22.
Life Insurance
$---------------------------------------------------
23. List any other payroll deductions (including 401 (k) contributions):
$---------------------------------------------------
$---------------------------------------------------
ATTACH a copy of your last pay slip to this form
Total Deductions
$--------------------------------------------------
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