Va Form 5655 - Financial Status Report (Page 2 of 2) in pdf

SECTION V - ASSETS

25. CASH IN BANK (Checking and savings accounts,

29. U.S. SAVINGS BONDS

building and loan accounts, etc.)

(Current Value)

30. STOCKS AND OTHER BONDS

26. CASH ON HAND

(Current Value)

31. REAL ESTATE OWNED

27. AUTOMOBILES (Resale value)

(Resale value)

MAKE

MODEL

YEAR

32. OTHER ASSETS (Specify below)

28. TRAILERS, BOATS, CAMPERS (Resale value)

33. TOTAL ASSETS

SECTION VI - INSTALLMENT CONTRACTS AND OTHER DEBTS

NOTE: Show below ALL debts which you are required to pay in regular monthly installments, such as a car, television, washing

machine, payments to dealers, banks, finance companies, repayment of money borrowed for any purpose, doctor bills, hospital bills,

etc. DO NOT INCLUDE LIVING EXPENSES.

DATE

ORIGINAL

AMOUNT

UNPAID

AMOUNT DUE

NAME AND ADDRESS OF CREDITOR

AND PURPOSE

AMOUNT OF

PAST DUE

BALANCE

MONTHLY

(If any)

OF DEBT

DEBT

(A)

(B)

(C)

(D)

(E)

(F)

34A.

34B.

34C.

34D.

34E.

34F.

34G.

34H.

34I. TOTAL

NOTE: If repayment of a debt is not on a monthly basis, write "0" in column E and describe arrangements to repay in Item 36.

SECTION VII - ADDITIONAL DATA

35A. HAVE YOU EVER BEEN ADJUDICATED BANKRUPT? IF SO AND VA OR A MORTGAGE COMPANY WAS INVOLVED, PLEASE SEND ALL PERTINENT

DOCUMENTATION

YES

(If "Yes," complete Items 35B through 35D)

35B. DATE DISCHARGED FROM BANKRUPTCY (MM-DD-YYYY)

35C. LOCATION OF COURT

35D. DOCKET NO. (If known)

36. USE THIS SPACE AND ADDITIONAL SHEETS, IF NECESSARY, TO SUPPLY ANY PERTINENT INFORMATION AND TO CONTINUE YOUR ANSWER TO

PREVIOUS ITEM NUMBER(S) TO WHICH YOUR COMMENTS APPLY

SECTION VIII - APPLICANT CERTIFICATIONS - REQUIRED

37B. DATE SIGNED

38B. DATE SIGNED

37A. YOUR SIGNATURE (Required )

38A. SIGNATURE OF SPOUSE (Required )

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,

knowing it to be false.

BACK OF VA FORM 5655, JUN 2009 (RS)

Va Form 5655 - Financial Status Report Page 2

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