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The VA 5655 form, also known as the Financial Status Report, is a crucial document utilized by the U.S. Department of Veterans Affairs to assess the financial situation of veterans and their families seeking benefits. This form gathers detailed information about income, expenses, assets, and liabilities, enabling the VA to determine eligibility for various programs such as pension benefits and financial aid. By capturing a comprehensive snapshot of an applicant's financial circumstances, the VA 5655 allows for informed decision-making and fair evaluation of claims. Applicants must provide current data on monthly income sources and any outstanding debts, including mortgage or rent payments, utilities, and personal expenses. Additionally, the form requires disclosure of savings and investments, ensuring a clear understanding of overall financial health. Completing this report accurately is essential, as it can significantly influence the level of assistance available to veterans and their dependents. Understanding the significance of the VA 5655 is essential for anyone navigating the benefits system and seeking financial support from the VA.

Form Sample

OMB Approved No. 2900-0165

Respondent Burden: 1 hour

 

 

FINANCIAL STATUS REPORT

 

 

 

1. SOCIAL SECURITY NO.

2. FILE NO.

3. SPECIFY WHY YOU ARE COMPLETING THIS FORM

 

 

(Waiver, Compromise, Payment Plan or Other)

 

 

 

(Type or print all entries. If more space is needed for any item, continue

 

under Section VII, Additional Data, Item 36 or attach separate sheet)

 

 

 

 

PRIVACY ACT INFORMATION: The information you furnish on this form is almost always used to determine if you are eligible for waiver of a debt, for the acceptance of a compromise offer or for a payment plan. Disclosure 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.

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, call 1-800-827-0648 for mailing information on where to send your comments.

SECTION I - PERSONAL DATA

4. FIRST-MIDDLE-LAST NAME OF PERSON

 

 

5. ADDRESS (Number and street or rural route, City or P.O. Box, State, and ZIP Code)

 

 

 

 

 

 

 

 

 

 

6. TELEPHONE NO. (Include Area Code)

7. DATE OF BIRTH (MM-DD-YYYY)

8. MARITAL STATUS

 

 

 

 

 

 

 

 

MARRIED

 

NOT MARRIED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. NAME OF SPOUSE

 

 

10. AGE(S) OF OTHER DEPENDENTS

 

 

 

 

 

 

 

 

 

COMPLETE RECORD OF EMPLOYMENT FOR YOURSELF AND SPOUSE DURING PAST 2 YEARS

 

 

 

 

 

 

 

 

KIND OF JOB

DATES (MM-YYYY)

 

 

 

NAME AND ADDRESS OF EMPLOYER

 

 

 

 

 

 

 

FROM

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. YOUR EMPLOYMENT EXPERIENCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRESENT TIME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. YOUR SPOUSE'S EMPLOYMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRESENT TIME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II - INCOME

SECTION III - EXPENSES

 

 

 

 

 

 

AVERAGE MONTHLY INCOME

SELF

 

SPOUSE

AVERAGE MONTHLY EXPENSES

AMOUNT

 

 

 

 

 

 

 

 

13. MONTHLY GROSS SALARY

$

 

$

18. RENT OR MORTGAGE PAYMENT

$

(Before payroll deductions)

 

 

 

 

 

 

14. PAYROLL DEDUCTIONS

 

 

 

19. FOOD

 

 

 

 

 

 

 

A. FEDERAL, STATE AND

 

 

 

20. UTILITIES AND HEAT

 

LOCAL INCOME TAXES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. RETIREMENT

 

 

 

21. OTHER LIVING EXPENSES

 

 

 

 

 

 

 

 

 

 

 

 

C. SOCIAL SECURITY

 

 

 

 

 

 

 

 

 

 

 

D. OTHER (Specify)

 

 

 

 

 

 

 

 

 

 

 

E. TOTAL DEDUCTIONS

 

 

 

 

 

(Items 14A through 14D)

 

 

 

 

 

 

 

 

 

 

 

15. NET TAKE HOME PAY

 

 

 

 

 

(Subtract Item 14E from Item 13)

 

 

 

 

 

 

 

 

 

 

 

16. VA BENEFITS, SOCIAL

 

 

 

 

 

SECURITY, OR OTHER INCOME

 

 

 

 

 

 

 

 

22. MONTHLY PAYMENTS ON INSTALLMENT

 

(Specify source)

 

 

 

 

 

 

 

CONTRACTS AND OTHER DEBTS (Include amount

 

 

 

 

 

 

 

 

 

 

from Section VI, Line 34I - Column E.)

 

 

 

 

 

 

 

17. TOTAL MONTHLY NET

$

 

$

23. TOTAL MONTHLY EXPENSES

$

 

 

INCOME (Item 15 plus Item 16)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION IV - DISCRETIONARY INCOME

 

 

 

 

 

 

24A. NET MONTHLY INCOME LESS EXPENSES (Item 17 less Item 23)

24B. AMOUNT YOU CAN PAY ON A MONTHLY BASIS TOWARD YOUR DEBT

$

 

 

 

$

 

 

 

 

 

 

 

VA FORM

JUN 2009 (RS) 5655

 

 

 

 

 

 

SECTION V - ASSETS

 

 

 

 

 

 

 

 

 

 

 

25. CASH IN BANK (Checking and savings accounts,

$

 

 

29. U.S. SAVINGS BONDS

$

 

building and loan accounts, etc.)

 

 

 

 

(Current Value)

 

 

26. CASH ON HAND

 

 

 

 

 

 

30. STOCKS AND OTHER BONDS

 

 

 

 

 

 

 

 

(Current Value)

 

 

 

 

 

 

 

 

 

 

 

 

27. AUTOMOBILES (Resale value)

 

 

 

 

31. REAL ESTATE OWNED

 

 

 

 

 

 

(Resale value)

 

 

 

 

 

 

 

 

 

 

 

 

MAKE

 

YEAR

 

MODEL

 

 

 

32. OTHER ASSETS (Specify below)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28. TRAILERS, BOATS, CAMPERS (Resale value)

$

33. TOTAL ASSETS

$

SECTION VI - INSTALLMENT CONTRACTS AND OTHER DEBTS

NOTE: Show below ALL debts which you are required to pay in regular monthly installments, such as a car, television, washing machine, payments to dealers, banks, finance companies, repayment of money borrowed for any purpose, doctor bills, hospital bills, etc. DO NOT INCLUDE LIVING EXPENSES.

 

NAME AND ADDRESS OF CREDITOR

DATE

ORIGINAL

UNPAID

AMOUNT DUE

AMOUNT

 

AND PURPOSE

AMOUNT OF

PAST DUE

 

BALANCE

MONTHLY

 

 

OF DEBT

DEBT

(If any)

 

(A)

 

 

 

(B)

(C)

(D)

(E)

(F)

 

 

 

 

 

 

 

34A.

 

 

 

 

 

 

 

 

$

 

$

$

$

 

 

 

 

 

 

 

34B.

 

 

 

 

 

 

 

 

 

 

 

 

 

34C.

 

 

 

 

 

 

 

 

 

 

 

 

 

34D.

 

 

 

 

 

 

 

 

 

 

 

 

 

34E.

 

 

 

 

 

 

 

 

 

 

 

 

 

34F.

 

 

 

 

 

 

 

 

 

 

 

 

 

34G.

 

 

 

 

 

 

 

 

 

 

 

 

 

34H.

 

 

 

 

 

 

 

 

 

 

 

 

 

34I. TOTAL

$

$

$

$

NOTE: If repayment of a debt is not on a monthly basis, write "0" in column E and describe arrangements to repay in Item 36.

SECTION VII - ADDITIONAL DATA

35A. HAVE YOU EVER BEEN ADJUDICATED BANKRUPT? IF SO AND VA OR A MORTGAGE COMPANY WAS INVOLVED, PLEASE SEND ALL PERTINENT DOCUMENTATION

YES

NO (If "Yes," complete Items 35B through 35D)

 

 

 

 

35B. DATE DISCHARGED FROM BANKRUPTCY (MM-DD-YYYY)

35C. LOCATION OF COURT

35D. DOCKET NO. (If known)

 

 

 

 

36.USE THIS SPACE AND ADDITIONAL SHEETS, IF NECESSARY, TO SUPPLY ANY PERTINENT INFORMATION AND TO CONTINUE YOUR ANSWER TO PREVIOUS ITEM NUMBER(S) TO WHICH YOUR COMMENTS APPLY

SECTION VIII - APPLICANT CERTIFICATIONS - REQUIRED

37A. YOUR SIGNATURE (Required )

37B. DATE SIGNED

38A. SIGNATURE OF SPOUSE (Required )

38B. DATE SIGNED

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact, knowing it to be false.

BACK OF VA FORM 5655, JUN 2009 (RS)

Document Specifications

Fact Name Description
Purpose The VA Form 5655, also known as the Financial Status Report, is used to gather information about a veteran's financial situation.
Eligibility This form is typically required for veterans seeking financial assistance or benefits from the VA.
Submission Process Veterans must complete and submit the form to their local VA office either online or via mail.
Information Required The form requests detailed information about income, expenses, assets, and liabilities.
Frequency of Use The form may need to be submitted annually, or whenever there are significant changes in financial circumstances.
Privacy Protections Submission of the form adheres to federal privacy laws that protect the personal information of veterans.
Governing Laws Relevant laws related to the form include Title 38 of the U.S. Code, which pertains to veteran benefits.

Steps to Filling Out VA 5655

Filling out the VA 5655 form is an important step in the claim process. After completing the form, it is crucial to submit it accurately to avoid delays. Be sure to gather all necessary information before you start.

  1. Read the instructions carefully. Familiarize yourself with what information is required.
  2. Provide personal information. This includes your name, address, and contact details at the top of the form.
  3. Fill out your financial information. Include details about your income, expenses, and assets in the designated sections.
  4. Disclose your employment status. Include information about your current and past jobs, if applicable.
  5. Sign and date the form. Make sure to provide your signature at the bottom of the document.
  6. Review the form. Check for any errors or missing information before submitting it.
  7. Submit the form. Send it via the method specified in the instructions, whether online or by mail.

More About VA 5655

What is the VA 5655 form?

The VA 5655 form, also known as the "Financial Status Report," is a form used by veterans to provide the Department of Veterans Affairs with information about their financial situation. This information helps the VA assess a veteran’s ability to pay for debts and obligations, especially in cases relating to benefits or compensation claims. The form collects details about income, expenses, assets, and liabilities.

Who needs to fill out the VA 5655 form?

How do I obtain the VA 5655 form?

The VA 5655 form is available on the official Department of Veterans Affairs website. You can download and print it directly from there. Additionally, you may visit your local VA office to request a hard copy. It's important to ensure that you have the latest version of the form to avoid delays in processing.

What information do I need to provide on the form?

While filling out the VA 5655, you need to provide comprehensive information about your finances. This includes your monthly income, monthly expenses, assets like bank accounts and property, and any debts or loans you owe. Be honest and thorough; the accuracy of your information significantly impacts your case. Attach any necessary documentation that supports your financial claims.

How is the information on the VA 5655 form used?

The VA uses the information from the VA 5655 form to evaluate your financial situation and determine your eligibility for various benefits, debt relief options, or other forms of assistance. Accurate details help the VA make informed decisions about your case, ensuring you receive the support you need.

What happens after I submit the VA 5655 form?

Once you submit the VA 5655 form, it will be reviewed by the VA. You may receive follow-up communication if additional information or clarification is required. The length of the review process can vary based on your case's complexity and the current workload of the VA. Stay in touch with your VA representative for updates and next steps.

Common mistakes

  1. Missing Personal Information: Applicants often forget to fill in their full name, address, and Social Security number. This information is crucial for the processing of the form.

  2. Inaccurate Financial Information: Many people provide incorrect figures for their income and expenses. Ensure that all amounts are accurate to avoid delays.

  3. Not Signing the Form: A common oversight occurs when individuals forget to sign and date the form. Without a signature, the VA cannot process the application.

  4. Failing to Include Necessary Documentation: Some applications lack important documents, such as proof of income or bank statements. Double-check requirements to prevent this mistake.

  5. Ignoring Dependency Information: Misreporting or omitting details about dependents can lead to complications. Clearly outline all relevant information to ensure accuracy.

  6. Neglecting to Review the Form: It is easy to overlook errors during the initial completion. Taking time to review the entire form can catch mistakes before submission.

  7. Submitting the Form Without a Copy: Always keep a copy of the submitted form for personal records. This can be helpful if any issues arise later.

  8. Not Seeking Assistance When Needed: Some applicants might hesitate to ask for help. Utilizing available resources, including veterans’ organizations, can simplify the process.

Documents used along the form

The VA 5655 form, also known as the Financial Status Report, is an important document for veteran affairs, particularly in the context of financial assistance programs. Along with this form, several other documents often play a key role in the application and review process for various benefits. Below are six additional forms and documents that are frequently associated with the VA 5655.

  • VA Form 526EZ: This is the application for disability compensation and related compensation benefits. It gathers critical information about a veteran's service-connected disabilities.
  • VA Form 21-4142: This is known as the Authorization to Disclose Information to the VA. It allows the VA to obtain necessary medical records and other information pertinent to a veteran's claims.
  • VA Form 21-527EZ: This form is used to apply for pension benefits. It collects financial information similar to what is found on the VA 5655, helping to determine eligibility for needs-based pension programs.
  • VA Form 21-22: This form appoints a service organization as the power of attorney for a veteran. It enables representatives to assist with claims and appeals on behalf of the veteran.
  • VA Form 21-0966: The Intent to File form indicates a claimant's intention to apply for benefits. It allows for the preservation of an effective date while gathering necessary documentation.
  • Income Verification Report: This document helps the VA verify a veteran's income, which is essential for determining eligibility for certain benefits. It typically includes information about wages, benefits, and other financial sources.

These documents complement the VA 5655 form, creating a comprehensive picture to assist veterans in navigating the benefits system. Having the correct forms prepared can streamline the application process and ensure that all necessary information is provided for evaluation.

Similar forms

The VA 5655 form, also known as the Financial Worksheet, assists veterans in demonstrating their financial circumstances when applying for various services or benefits. One similar document is the form required for income verification by Social Security Administration (SSA). Both documents gather financial information to determine eligibility for assistance programs. They require a detailed account of income sources, expenses, and assets, thereby providing a comprehensive overview of a person's financial situation.

An additional document comparable to the VA 5655 is the Household Report used in state and federal housing assistance programs. Like the VA 5655, the Household Report asks for a breakdown of income and expenses, focusing on household members. This helps agencies assess if applicants qualify for housing aid based on their financial realities.

The Financial Aid Application (FAFSA) is yet another form that shares similarities with the VA 5655. It collects detailed financial information from students and their families to assess eligibility for federal aid. Both forms delve into income, assets, and household size. This comprehensive data collection ensures fair access to financial resources for education and support services.

The IRS Form 4506-T, Request for Transcript of Tax Return, also resembles the VA 5655 in its purpose. Individuals may use this document to request tax information, but it can also serve to verify income when applying for loans or assistance programs. Both forms aim to provide a clear picture of financial standings to relevant authorities.

Lastly, the Temporary Assistance for Needy Families (TANF) application reflects similar elements. This application asks for detailed financial information to determine eligibility for temporary cash assistance. Just like the VA 5655, it requires transparency about income, necessary expenses, and family size, which helps ensure that resources go to those who truly need them.

Dos and Don'ts

When filling out the VA Form 5655, it is important to follow proper guidelines to ensure the form is completed correctly. Below is a list of things to do and not do when completing this form.

  • Do read all instructions carefully before starting.
  • Do provide accurate and complete information.
  • Do double-check your calculations, if applicable.
  • Do sign and date the form before submitting it.
  • Don't leave any required fields blank.
  • Don't use white-out or erasers on the form.
  • Don't submit the form without making a copy for your records.
  • Don't rush through the process; take your time to ensure accuracy.

Misconceptions

The VA 5655 form, officially known as the Financial Status Report, can be a source of confusion for many. Here are four common misconceptions about this important document and the reality behind each one.

  • Misconception 1: The VA 5655 form is only for veterans experiencing financial hardship.
  • This is not entirely true. While the form is often associated with financial difficulties, it can also be used by veterans who wish to report changes in their financial situation, regardless of whether they are facing hardships.

  • Misconception 2: Filling out the VA 5655 form is optional.
  • In certain situations, such as applying for certain benefits or appealing decisions made by the VA, completing the VA 5655 is mandatory. Failing to submit this form when required can significantly impact one's benefits or claims process.

  • Misconception 3: Only income needs to be reported on the VA 5655 form.
  • In reality, the form requires detailed information about more than just income. It also encompasses assets, expenses, and debts, providing a comprehensive view of an individual’s financial situation.

  • Misconception 4: Once submitted, the information on the VA 5655 form cannot be changed.
  • This is incorrect. If circumstances change, veterans can update their information by submitting a new VA 5655 form. Keeping the VA informed about financial changes is crucial for accurate assessments of eligibility and benefits.

Key takeaways

The VA 5655 form, also known as the Financial Status Report, is important for veterans seeking financial assistance. Here are some key points to keep in mind when filling it out and using it:

  • Provide complete and accurate information. The VA uses your financial details to assess your eligibility for benefits.
  • Include your monthly income and expenses. This helps the VA understand your financial situation better.
  • Report all sources of income. This includes wages, retirement benefits, and disability payments.
  • Be prepared to provide documentation. Pay stubs, bank statements, and bills may be requested for verification.
  • Indicate any debts and liabilities. List loans, credit card debts, and other financial obligations clearly.
  • Check for errors before submission. Mistakes can delay the processing of your request.
  • Submit the form on time. Make sure you meet any deadlines to avoid complications with your benefits.
  • Keep copies of everything you send. This helps in case you need to follow up on your application.