Fillable Form VA 5655
VA Form 5655 is a form that is meant to provide information about a veteran's financial status, and is usually used to determine which benefits the veteran may be eligible for, such as debt exemptions or payment plans.
What is the VA Form 5655?
VA Form 5655, officially known as the Financial Status Report, is a Department of Veterans Affairs (VA) form used to supply information regarding your current financial situation.
Through this form, your eligibility for payment plans, debt exemptions, compromise offers, and other benefits will be validated.
If you are a veteran, beneficiary, payee, a representative acting on the debtor's behalf, or the representative of an estate, you may use this form.
How to fill out the VA Form 5655?
Make sure to fill in each section completely and accurately.
The form contains eight (8) sections:
Box 1
Enter your Social Security Number (SSN).
Box 2
Enter the file number.
Box 3
Enter the reason for completing the form (Compromise, Payment Plan, Waiver, or Other).
Section I - Personal Data
Box 4
Enter your full name.
Box 5
Enter your full address (number and street or rural code, city or P.O. Box, state, and ZIP code).
Box 6
Enter your telephone number with the area code.
Box 7
Enter your date of birth.
Box 8
Select “Yes” if you are married. If not, select “No”.
Box 9
Enter the name of your spouse.
Box 10
Enter 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
Enter the information required from you and your spouse on the appropriate column.
Box 13
Enter 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
Enter 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 Enterd.
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
Enter your signature.
Box 37b
Enter the date when you signed.
Box 38a
Let your spouse sign.
Box 38b
Enter the date when your spouse signed.
Submission
There are different modes to submit the VA form 5655. It may be submitted via fax, mail, or email.
If you will submit via fax, send the form to the number 1-612-970-5798.
If you will submit through the mail, send the completed 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 email, send the form to [email protected] with the purpose of the form (Payment Plan, Waiver, Repay, or Repay and Waiver) specified in the subject line.
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