VA5655
Financial Status Report
VA Form VA5655 is the U.S. Department of Veterans Affairs Financial Status Report. Its Privacy Act notice says the information on the form is almost always used to determine eligibility for waiver of a debt, for the acceptance of a compromise offer or for a payment plan. Item 3 asks which of these the form is being completed for: Waiver, Compromise, Payment Plan or Other.
The form is two pages in eight sections: personal data and two years of employment history, monthly income, monthly expenses, discretionary income, assets, installment contracts and other debts, additional data, and the certifications signed by the applicant and spouse. The form says to type or print all entries.
VA's form page says the request can also be submitted online instead of filling out and sending the paper form. You can fill out the PDF free in your browser on this page and download the result without an account.
Social Security number, file number and the reason for the form, then name, address, telephone, date of birth, marital status, spouse's name, ages of other dependents and a complete record of employment for yourself and your spouse during the past 2 years.
Average monthly gross salary, payroll deductions for taxes, retirement, Social Security and other items, net take home pay, VA benefits, Social Security or other income, and total monthly net income, for self and spouse.
Rent or mortgage, food, utilities and heat, other living expenses and monthly payments on installment contracts and other debts, then net monthly income less expenses and the amount that can be paid each month toward the debt.
Cash in bank and on hand, automobiles with make, year, model and resale value, trailers, boats and campers, U.S. Savings Bonds, stocks and other bonds, real estate owned, other assets and total assets.
Rows 34A to 34H for each creditor's name and address, the date and purpose of the debt, original amount, unpaid balance, amount due monthly and any amount past due, with totals in 34I. The form says not to include living expenses here.
Bankruptcy questions in Items 35A to 35D, space in Item 36 to add or continue answers, and the signatures and dates of the applicant and spouse, followed by the penalty statement.
Write why the form is being completed: Waiver, Compromise, Payment Plan or Other.
The form says to type or print all entries. If more space is needed for any item, it says to continue under Section VII, Item 36, or attach a separate sheet.
Sections II and III ask for average monthly income and expenses. Item 22 includes the amount from Section VI, line 34I, column E.
The note in Section VI says to show all debts paid in regular monthly installments. If repayment of a debt is not monthly, it says to write 0 in column E and describe the arrangements in Item 36.
Item 35A asks about any bankruptcy. If the answer is yes, Items 35B to 35D ask for the discharge date, court location and docket number, and the form asks for all pertinent documentation where VA or a mortgage company was involved.
Sign Item 37A and date Item 37B. Item 38A, the signature of spouse, is also marked required.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
VA's form page says you can submit your request online instead of filling out and sending the paper form.
Neither the PDF nor VA's form page prints a mailing address for the paper form.
The respondent burden statement gives 1-800-827-0648 to get information on where to send comments or suggestions about the form.
The current edition is dated JAN 2024 (RS). It carries OMB Approved No. 2900-0165, an expiration date of Nov 30, 2026 and a respondent burden of 1 hour.
The form's Privacy Act notice and Item 3 describe what the report is used for.
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The Privacy Act notice says the information is almost always used to determine eligibility for waiver of a debt, for the acceptance of a compromise offer or for a payment plan.
Yes. VA's form page says you can submit your request online instead of filling out and sending the paper form.
The form marks Item 38A, the signature of spouse, as required, next to the applicant's signature in Item 37A.
A complete record of employment for yourself and your spouse during the past 2 years, with dates, kind of job and the employer's name and address.
The form says to write 0 in column E of Section VI and describe the arrangements to repay in Item 36.
The Privacy Act notice says disclosure is voluntary, but if the information is not furnished, eligibility for waiver, compromise or a payment plan may be affected.
The notice says responses are considered confidential under 38 U.S.C. 5701 and may be disclosed outside VA only when authorized by the Privacy Act, including in computer matching programs with other Federal or State agencies.
