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THIS IS IN RESPONSE TO YOUR REQUEST TO ESTABLISH A MONTHLY PAYMENT

By Bruce Bradley,2014-05-18 18:17
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THIS IS IN RESPONSE TO YOUR REQUEST TO ESTABLISH A MONTHLY PAYMENT

    STATEMENT OF FINANCIAL STATUS

    FEDERAL EMPLOYEE SALARY OFFSET PROGRAM

YOUR NAME ______________________________ YOUR SSN ______________________

1.AMOUNT YOU ARE PROPOSING TO PAY EACH MONTH: $__________

***************** HOUSEHOLD AND EMPLOYMENT INFORMATION ****************

2.YOUR ADDRESS _____________________________________________________

     _____________________________________________________

     _____________________________________________________

3.COUNTY IN WHICH YOU LIVE:____________________ HOME PHONE _____________

4.EMPLOYER’S NAME _____________________________________________________

5.EMPLOYER’S _____________________________________________________

     ADDRESS

     _____________________________________________________

6.EMPLOYER’S PHONE ________________ YOUR JOB TITLE _____________________

7.NUMBER OF DEPENDENTS (AS DEFINED BY IRS) INCLUDING SELF: _____________

8.MARITAL STATUS (MARRIED, SINGLE, DIVORCED): _____________

9.SPOUSE’S NAME AND SSN: _______________________________________________

**************************** MONTHLY INCOME **************************

NOTE: GROSS INCOME IS INCOME BEFORE ANY DEDUCTIONS SUCH AS TAXES. NET

    INCOME IS YOUR TAKE-HOME PAY. INCLUDE RECENT PAY STUBS AND TAX RETURNS.

10.YOUR AVERAGE MONTHLY INCOME GROSS $__________ NET $__________

    11.YOUR SPOUSE’S AVG MONTHLY INCOME GROSS $__________ NET $__________ 12.OTHER CONTRIBUTING RESIDENT(S) AVG MONTHLY INCOME NET $__________

    13.OTHER(ALIMONY, ETC. DESCRIBE_________________________)NET $__________

************************** MONTHLY EXPENSES ***************************

14.RENT/MORTGAGE (TO WHOM:_________________________________)$__________

    15.PROPERTY TAX $__________

    16.HOME/RENTER’S INSURANCE $__________

    17.FOOD $__________

    18.CLOTHING $__________

    19.ELECTRICITY $__________

    20.NATURAL GAS/HEATING OIL/PROPANE $__________

    21.WATER/SEWER/TRASH DISPOSAL $__________

    - CONTINUED ON PAGE 2

    - STATEMENT OF FINANCIAL STATUS PAGE 2 MONTHLY EXPENSES CONTINUED

    22.BASIC PHONE SERVICE $__________ 23.CAR PAYMENT (FIRST CAR) $__________ 24.CAR PAYMENT (SECOND CAR) $__________ 25.AUTO FUEL AND MAINTENANCE $__________ 26.PUBLIC TRANSPORTATION $__________ 27.AUTO INSURANCE $__________ 28.MEDICAL INSURANCE PAYMENTS NOT DEDUCTED FROM PAYCHECK $__________ 29.MEDICAL CO-PAYMENTS AND EXPENSES NOT COVERED BY INSURANCE $__________ 30.CHILD CARE EXPENSES(NUMBER OF CHILDREN:_______) $__________ 31.CHILD SUPPORT (NUMBER OF CHILDREN:_______) $__________

LIST ANY OTHER MONTHLY EXPENSES BELOW:

    32._________________________________________________________ $__________ 33._________________________________________________________ $__________ 34._________________________________________________________ $__________

    ******************************** ASSETS ********************************

    35.BANK ACCOUNT 1(BANK NAME:_______________________________) $__________ 36.BANK ACCOUNT 2(BANK NAME:_______________________________) $__________ 37.BANK ACCOUNT 3(BANK NAME:_______________________________) $__________ 38.STOCKS/BONDS (BANK NAME:_______________________________) $__________ 39.HOME VALUE:$__________ OWED:$__________ 40.OTHER REAL ESTATE VALUE:$__________ OWED:$__________ 41.CAR 1(YR,MAKE,MODEL:______________)VALUE:$__________ OWED:$__________ 42.CAR 2(YR,MAKE,MODEL:______________)VALUE:$__________ OWED:$__________

    *************************** SWORN STATEMENT ****************************

    I DECLARE UNDER PENALTIES PROVIDED BY 18 U.S.C. SECTION 1001, THAT THE ANSWERS AND STATEMENTS CONTAINED HEREIN ARE TO THE BEST OF MY KNOWLEDGE AND BELIEF TRUE, CORRECT AND COMPLETE.

    43.SIGNATURE:____________________________________DATE:_________________

     SOCIAL SECURITY NUMBER: ______________________

    WARNING:18 U.S.C. 1001 PROVIDES THAT "WHOEVER...KNOWINGLY AND WILLFULLY FALSIFIES, CONCEALS OR COVERS UP BY ANY TRICK, SCHEME, OR DEVICE A MATERIAL FACT, OR MAKES ANY FALSE, FICTITIOUS OR FRAUDULENT STATEMENTS OR REPRESENTATION.., SHALL BE FINED NOT MORE THAN $10,000.00, OR IMPRISONED NOT MORE THAN FIVE YEARS, OR BOTH".

RETURN THIS FORM AND ALL REQUIRED DOCUMENTATION TO:

     U.S. DEPARTMENT OF EDUCATION

     ATTN: HEARINGS UNIT

     PO BOX 4227

     IOWA CITY, IA 52244-4222

    STATEMENT OF FINANCIAL STATUS

    INSTRUCTIONS

    THIS STATEMENT OF FINANCIAL STATUS FORM HAS BEEN SENT IN RESPONSE TO YOUR REQUEST TO ESTABLISH A MONTHLY PAYMENT PLAN. IN ORDER TO DETERMINE A PAYMENT AMOUNT THAT IS BOTH AFFORDABLE FOR YOU AND REASONABLE BASED ON THE AMOUNT YOU OWE, YOU MUST COMPLETE AND RETURN IT.

    1. IMMEDIATELY BEGIN SENDING THE AMOUNT YOU PROPOSE TO PAY EACH MONTH TO:

     U.S. DEPARTMENT OF EDUCATION

     PO BOX 4169

     GREENVILLE, TX 75403-4169

    INCLUDE YOUR NAME AND SOCIAL SECURITY NUMBER ON YOUR CHECK OR MONEY ORDER. TO MAKE PAYMENT BY CREDIT CARD CALL 800-621-3115. DO NOT SEND CASH.

    2. COMPLETE EVERY FIELD ON THIS FORM. IF AN ANSWER IS ZERO, WRITE ZERO.

    3. INCLUDE PROOF OF YOUR HOUSEHOLD INCOME FOR BOTH YOU AND YOUR SPOUSE (FOUR MOST RECENT LEAVE AND EARNINGS STATEMENTS AND TWO MOST RECENT FEDERAL INCOME TAX RETURNS), AND PROOF OF YOUR EXPENSES (SUCH AS COPIES OF MONTHLY BILLS AND/OR CANCELLED CHECKS).

    4. DO NOT INCLUDE MONTHLY PAYMENTS ON CREDIT CARDS IF THE ITEMS PURCHASED BY THAT CREDIT CARD FIT UNDER AN EXPENSE CATEGORY LISTED. INCLUDE THOSE COSTS UNDER THAT EXPENSE CATEGORY. FOR EXAMPLE, PAYMENTS ON CREDIT CARDS USED TO PURCHASE CLOTHING SHOULD BE LISTED UNDER CLOTHING EXPENSES.

    5. IF YOU ARE PAYING SOME EXPENSES QUARTERLY OR ANNUALLY, SUCH AS AUTOMOBILE INSURANCE, CALCULATE THE AMOUNT THAT WOULD BE DUE IF THESE EXPENSES WERE PAID MONTHLY AND PUT THAT AMOUNT IN THE SPACE PROVIDED.

    6. RETURN THE COMPLETED FORM TO: U.S. DEPARTMENT OF EDUCATION

     ATTN: HEARINGS UNIT

     PO BOX 4227

     IOWA CITY, IA 52244-4222

    7. WE WILL NOTIFY YOU IN WRITING ONCE WE DETERMINE AN ACCEPTABLE MONTHLY PAYMENT AMOUNT. YOU MAY CONTACT US AT 800-621-3115 FOR FURTHER ASSISTANCE.

     PRIVACY ACT NOTICE

    THIS REQUEST IS AUTHORIZED UNDER 31 U.S.C. 3711,20 U.S.C. 1078-6, AND 20 U.S.C. 1095A. YOU ARE NOT REQUIRED TO PROVIDE THIS INFORMATION. IF YOU DO NOT, WE CANNOT DETERMINE YOUR FINANCIAL ABILITY TO REPAY YOUR STUDENT AID DEBT. THE INFORMATION YOU PROVIDE WILL BE USED TO EVALUATE YOUR ABILITY TO PAY. IT MAY BE DISCLOSED TO GOVERNMENT AGENCIES AND THEIR CONTRACTORS, TO EMPLOYERS, LENDERS, AND OTHERS TO ENFORCE THIS DEBT; TO THIRD PARTIES IN AUDIT, RESEARCH, OR DISPUTE ABOUT THE MANAGEMENT OF THIS DEBT; AND TO PARTIES WITH A RIGHT TO THIS INFORMATION UNDER THE FREEDOM OF INFORMATION ACT OR OTHER FEDERAL LAW OR WITH YOUR CONSENT. THESE USES ARE EXPLAINED IN NOTICE IN THE STUDENT FINANCIAL ASSISTANCE COLLECTION FILES, NO 18-11-07; WE WILL SEND A COPY AT YOUR REQUEST.

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