Fillable Form VA 5655

What is VA Form 5655?

VA Form 5655, officially the Financial Status Report, is a form used to supply information regarding your current financial situation to the Department of Veterans Affairs (VA)in the United States.

Your eligibility for payment plans, debt exemptions, compromise offers, and other benefits will be validated through this form.

You are eligible to use this form if you are a veteran, beneficiary, payee, a representative acting on the debtor's behalf, or the representative of an estate.

How to fill out Form 5655?

The form contains the following sections:

• Personal Data
• Income
• Expenses
• Discretionary Income
• Assets
• Installment Contracts and Other Debts
• Additional Data
• Applicant Certifications

Make sure to fill in each section completely and accurately. If more space is needed for any item, enter it on Section VII, Additional Data, Item 36, or attach a separate sheet.

Box 1
Provide your Social Security Number (SSN).

Box 2
Enter the file number.

Box 3
Provide the reason for completing the form - either Compromise, Payment Plan, Waiver, or Other.

Section I - Personal Data

Box 4
Provide your full name.

Box 5
Provide your full address (number and street or rural code, city or P.O. Box, state, and ZIP code).

Box 6
Provide your telephone number with the area code.

Box 7
Provide your date of birth.

Box 8
Select “Yes” if you are married. If not, select “No”.

Box 9
Provide the name of your spouse.

Box 10
Provide the age(s) of other dependents.

Box 11
Complete your record of employment for the past 2 years including the name and address of your employer.

Box 12
Complete the record of employment of your spouse for the past 2 years. Include the name and address of the employer.

Section II- Income
Provide the information required from you and your spouse on the appropriate column.

Box 13
Provide the gross monthly salary without payroll deductions.

Box 14a
Enter the payroll deductions under federal, state, and local income taxes.

Box 14b
Enter the payroll deductions under retirement.

Box 14c
Enter the payroll deductions under social security.

Box 14d
Enter the payroll deductions under other categories not listed above.

Box 14e
Add all amounts entered in Box 14a to Box 14d.

Box 15
Subtract Box 14E from Box 13 and enter it here.

Box 16
Enter the amount obtained from VA benefits, social security, disability benefits, or other income sources.

Box 17
Add the amounts entered in Box 15 and Box 16.

Section III- Expenses

Box 18
Enter the amount you spend on rent or mortgage payment.

Box 19
Enter the amount you spend on food.

Box 20
Enter the amount you spend on utilities and heat.

Box 21
Enter the amount you spend on other expenses.

Box 22
Enter your monthly payments on installment contracts and other debts.

Box 23
Add the amounts entered in Box 18 to Box 22 and enter it here as total monthly expenses.

Section IV - Discretionary Income

Box 24a
Subtract Box 23 from Box 17 and enter it here.

Box 24b
Provide the amount you can pay on a monthly basis toward your debt.

SECTION V - ASSETS

Box 25
Enter the amount you have in the bank.

Box 26
Enter the amount you have on hand.

Box 27
Enter the resale value of your automobile(s).

Box 28
Enter the resale value of your trailers, boats, and campers

Box 29
Enter the current value of your U.S. savings bonds.

Box 30
Enter the current value of your stocks and other bonds.

Box 31
Enter the resale value of the real estate you own.

Box 32
Enter the value of your other assets and specify it on the space provided.

Box 33
Add boxes 25 to 32 and enter it here as your total assets.

Section VI - Installment Contracts and Other Debts

Boxes 34a to 34h
Name and address of creditor, date, and purpose of debt, original amount of debt, unpaid balance, the amount due monthly, amount past due.

Section VII - Additional data

Box 35a
Select “Yes” if you have been adjudicated bankrupt and answer Box 35b to 35d. If not, select “No”.

Box 35b
Enter the date you were discharged from bankruptcy.

Box 35c
Enter the location of the court.

Box 35d
Enter the docket number.

Box 36
Enter any additional information that is pertinent to the application.

Section VIII - Applicant Certifications

Box 37a
Provide your signature.

Box 37b
Provide the date when you signed.

Box 38a
Let your spouse sign.

Box 38b
Provide the date when your spouse signed.

Submission

VA form 5655 may be submitted via mail, fax, or email.

If you will submit through the mail, send the form to:

U.S. Department of Veterans Affairs
Debt Management Center
P.O. Box 11930
St. Paul, MN 55111
1-612-970-5688 (fax)

If you will submit via fax, send the form to the number 1-612-970-5798.

If you will submit via email, send the form to [email protected] with the purpose of the form (either Payment Plan, Waiver, Repay, or Repay and Waiver) specified in the subject line.

Form VA 5655 may be submitted anytime along with the main documents such as VA financial hardship form, VA debt waiver form, request for a compromise offer.

When filing the VA 5655 to accompany a request for a compromise offer, no payments should be sent. Payment may be only sent along with this form when requesting a monthly payment plan. When requesting a waiver, attach a letter that explains the reason for the request.

Remember to keep yourself a copy of each document you send to the Debt Management Center.

Aside from Form VA 5565, you may access other VA forms online. If you want to file an application for compensation and/or pension, use VA form 21-526. If the VA recently denied your claim for disability benefits, then use VA form 21-4192. If you want to claim due to injury or damage, use VA form 95.