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.