There are two options (Portable Document File or Fillable Form) to complete the Financial Status Report Form. Adobe Acrobat Reader is required to complete the Financial Status Report in either format.
Refer to our Financial Status Report or Most Frequently Asked Questions and contact us directly at 1-800-827-0648 for more information. International callers may contact us directly at 1-612-713-6415.
Be sure to read the special instructions, below, before completing either form.
Compromise Offer: If you are completing this form to accompany a request for a compromise offer, please ensure that you sign the form. Do not send a payment with the completed form. For more information, refer to Submitting a Compromise Offer.
Monthly Payment Plan: If you are completing this form to request a monthly payment plan, please sign the form and ensure that you complete Block 24B with the amount you propose to pay on a monthly basis. You may send a payment with your completed form. For more information, refer to Payment Options.
Waiver Request: If you are completing this form to accompany your request for a waiver, please ensure that you sign the form and include with your request. For more information, see Submitting a Waiver Request.
Additional Questions: If you have additional questions that are not listed on the Frequently Asked Questions page, please do not hesitate to call 1-800-827-0648 for more information.
Privacy Act Information: The information you furnish on this form is used to determine if you are eligible for waiver of a debt, for the acceptance of a compromise offer or for a payment plan. Disclose is voluntary. However, if the information is not furnished, your eligibility for waiver, compromise or a payment plan may be affected. The responses you submit are confidential and protected from unauthorized disclosure by 38 U.S.C. 5701. The information may be disclosed outside the Department of Veterans Affairs (VA) only when authorized by the Privacy Act of 1974, as amended. The routine uses for which VA may disclose the information can be found in VA systems of records, including 58VA21/22, Compensation, Pension, Education and Rehabilitation Records-VA, and 88VA244, Accounts Receivable Records-VA. VA systems of records and alterations to the systems are published in the Federal Register.
Any information provided by you, including your Social Security Number, may be used in computer matching programs conducted in connection with any proceeding for the collection of an amount owed by virtue of your participation in any benefit program administered by VA. The responses you submit are considered confidential (38 U.S.C. 5701). They may be disclosed outside the Department of Veterans Affairs (VA) only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records, 88VA244, “Accounts Receivable Records-VA” and 58VA21/22, “pCompensation, Pension, Education and Rehabilitation Records-VA” published in the Federal Register.
Respondent Burden: VA may not conduct or sponsor and respondent is not required to respond to this collection of information unless it displays a valid OMB control number.
Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
If you have comments regarding this burden estimate or any other aspect of this collection of information, contact:
U.S. Department of Veterans Affairs
Debt Management Center
P.O. Box 11930
St. Paul, MN 55111
Toll Free: 1-800-827-0648
Note: You may need to visit the VA Viewer Software page to view the documents available on this page.