Items 1 to 6: Debtor and spouse
Debtor's name, birth date, home address and phone number, and the spouse's name, address if different and date of birth.
CMS-379
FINANCIAL STATEMENT OF DEBTOR
- Agency
- CMS
- Revision
- 07/07
- Fillable fields
- 211
- Pages
- 4
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-379: Financial Statement of Debtor
Form CMS-379 is the Financial Statement of Debtor from the Centers for Medicare & Medicaid Services, part of the U.S. Department of Health and Human Services. Its subtitle says it is submitted for Government action on claims due the United States. The form says the principal purpose for gathering the information is to evaluate your capacity to pay the Government's claim against you.
The form says disclosure is voluntary, and that if the requested information is not furnished, the Government will pursue immediate and full payment of its claim. Its four pages cover the debtor's and spouse's employment and income, dependents, monthly expenses, loans, assets and liabilities, real estate, life insurance and property transfers, then a set of yes or no questions and a signed certification.
The form shows OMB No. 0938-0270. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-379
Items 7 to 16: Employment and income
For the debtor and the spouse: occupation, time in present employment, present employer, other employment within the last 3 years, and present monthly income from salary or wages, commissions and other sources.
Items 17 to 21: Dependents and tax return
Dependents and their income, the period of the last federal income tax return filed, where it was filed and the amount of gross income reported.
Items 22 to 24: Expenses, loans, assets and liabilities
Fixed monthly expenses (rent, food, utilities, interest, debt repayments, other), loans payable with original amount and present balance, and assets at fair market value set against liabilities.
Items 25 to 29: Property and transfers
Real estate owned or being purchased under contract, life insurance policies, property of the spouse and dependents valued over $200, and transfers of property of $300 or over made within the last 3 years.
Items 30 to 34 and certification
Yes or no questions on pending lawsuits, acting as trustee, executor or administrator, moneys held on your behalf, a likely inheritance and expected benefits, then a dated, signed certification.
The form has 34 numbered items over four pages. It says to use additional sheets where space is insufficient or continue on the reverse side.
How to fill out Form CMS-379
- 1
Read the purpose statement
The top of page 1 gives the authority (42 CFR 405.376; 4 CFR 101, et seq.; 31 U.S.C. 951, et seq.), the purpose and what happens if the information is not furnished.
- 2
Enter personal and employment data
Complete items 1 to 16 for the debtor and the spouse, including employment within the last 3 years and present monthly income.
- 3
Add dependents and tax return details
Fill in items 17 to 21: dependents, their monthly income, and the last federal income tax return filed.
- 4
List expenses, loans, assets and liabilities
Complete items 22 to 24, itemizing where the form asks, and fill in Total Assets and Total Liabilities.
- 5
Describe property and answer the questions
Complete items 25 to 29, then answer items 30 to 34. A Yes answer has space for details.
- 6
Sign and date
Read the certification on page 4, then enter the date and sign.
Why fill Form CMS-379 on indox
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- Works on a phone, tablet or computer
Sending the form and what it says
Where to send it
The form does not print a mailing address for the statement. The CMS address on page 4 is for comments on the time estimate only.
Voluntary disclosure
The form says disclosure of the information is voluntary. It also says that if the requested information is not furnished, the Government will pursue immediate and full payment of its claim.
False statements
The certification refers to the penalties for false statements in 18 United States Code 1001, which it lists as a $10,000 fine and/or 5 years imprisonment.
Time to complete
The form estimates an average of 2 hours per response, including reviewing instructions and gathering the data needed.
OMB number
The form shows OMB No. 0938-0270. It does not print an expiration date; the CMS page lists 2027-12-31.
Related forms
Who uses Form CMS-379?
The form is completed by the debtor named in item 1 and asks about the debtor's household.
Official sources and the blank
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Questions about Form CMS-379
What is Form CMS-379 used for?
The form says the principal purpose for gathering the information is to evaluate your capacity to pay the Government's claim against you. Its subtitle says it is submitted for Government action on claims due the United States.
Is filling out Form CMS-379 voluntary?
The form says disclosure is voluntary. It adds that if the requested information is not furnished, the Government will pursue immediate and full payment of its claim.
Does Form CMS-379 ask about my spouse?
Yes. Items 5, 6 and 12 to 16 ask for the spouse's name, date of birth, employment and monthly income, and item 28 lists property owned by the spouse and dependents valued over $200.
What if there is not enough space on the form?
The form says to use additional sheets where space is insufficient or to continue on the reverse side of pages.
Which property transfers go on the form?
Item 29 asks for all transfers of property, including cash, by loan, gift, sale or otherwise, made within the last 3 years, for items of $300 or over.
How long does Form CMS-379 take?
The form estimates an average of 2 hours per response.