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The VA 5655 form, officially known as the Financial Status Report, plays a crucial role in assisting veterans and their families to navigate the intricacies of veterans' benefits and financial support. This form is primarily used to evaluate an individual’s financial situation, allowing the Department of Veterans Affairs (VA) to determine eligibility for various programs, including debt relief, granted benefits, and assistance with loans. With its structured layout, the VA 5655 gathers essential information, such as income, expenses, assets, and liabilities, allowing for a comprehensive assessment of one’s financial position. By accurately completing this form, veterans can communicate their current economic challenges and seek the necessary support they may require. It is important for individuals to understand the significance of transparency and precision when filling out the VA 5655, as this can influence the outcomes of their requests for aid. Overall, the VA 5655 serves as a vital tool in ensuring that those who have bravely served the nation receive the assistance they deserve during financially difficult times.

VA 5655 Example

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)

File Breakdown

Fact Name Description
Purpose The VA 5655 form is used for requesting financial assistance from the Department of Veterans Affairs.
Eligibility This form is applicable to veterans, active duty service members, and their families seeking aid.
Application Process Applicants must fill out the form accurately and submit it to the appropriate VA office for consideration.
Information Required The form requires personal information, financial details, and information about the applicant's military service.
Supporting Documents Applicants may be required to provide additional documentation, such as proof of income or service records.
State-Specific Forms Some states may have specific regulations regarding the use of the VA 5655 form, governed by laws such as Title 38 of the U.S. Code.
Submission Methods The form can typically be submitted through mail, online portals, or in-person visits to VA facilities.
Processing Time The time needed to process the VA 5655 form varies but can take several weeks depending on the complexity of the claim.
Important Notes Keep copies of all submitted documents and track your application status for better oversight of the process.

Guide to Using VA 5655

Once you have gathered the necessary information, you can begin filling out the VA 5655 form. This form is essential for providing the Department of Veterans Affairs with the data needed for processing a financial assessment. It's important to ensure all sections are completed accurately, as this will facilitate a smoother evaluation of your needs.

  1. Start by carefully reading the instructions at the top of the form.
  2. Fill in your personal information in the designated sections, including your name, address, and contact information.
  3. Provide your Social Security number in the appropriate field.
  4. Document your service history, detailing the branch of military service and dates of service.
  5. Indicate your current financial situation, including income sources, monthly expenses, and debts.
  6. Attach any required supporting documents that verify income and expenses, if necessary.
  7. Review the completed form for any errors or missing information.
  8. Sign and date the form at the designated area to affirm the accuracy of the information provided.
  9. Submit the form according to the instructions given, ensuring it reaches the relevant department promptly.

Get Answers on VA 5655

What is the VA 5655 form?

The VA 5655 form, also known as the Financial Status Report, is used by veterans to provide a detailed account of their financial situation when applying for assistance from the Department of Veterans Affairs. This form gathers information about income, expenses, assets, and liabilities, which helps the VA determine eligibility for various programs and benefits.

Who needs to fill out the VA 5655 form?

Veterans or their families may need to complete the VA 5655 form when seeking financial assistance or benefits from the VA. This includes individuals applying for a waiver of certain fees, veterans who are experiencing financial hardship, or those seeking to participate in programs like the VA Home Loan Guaranty or other service-connected benefits. Proper completion of this form is essential for a fair assessment of financial need.

How do you fill out the VA 5655 form?

Filling out the VA 5655 form involves several steps:

  1. Gather financial documents, including proof of income, monthly expenses, and asset information.
  2. Complete each section of the form, providing accurate and up-to-date information regarding your financial status.
  3. Review the completed form for accuracy and ensure all required fields are filled out.
  4. Submit the form as instructed, either online, through the mail, or in person, depending on the specific circumstances of your application.

What happens after submitting the VA 5655 form?

Once the VA 5655 form is submitted, the Department of Veterans Affairs will review the information provided. This review process typically includes assessing the veteran’s financial situation to determine eligibility for benefits or assistance programs. The timeframe for processing can vary, but applicants can usually expect to hear back within a few weeks to several months, depending on the specifics of their case and the volume of applications being processed.

Is the information on the VA 5655 form confidential?

Yes, the information provided on the VA 5655 form is considered confidential. The VA has strict guidelines concerning the handling and security of personal data to protect veterans' privacy. Only authorized personnel within the VA will have access to the information, and it will not be shared without the explicit consent of the individual except as required by law. Maintaining your privacy is a priority during the application process.

Common mistakes

Filling out the VA 5655 form, known as the Financial Status Report, is a crucial step for veterans seeking benefits. However, many people make errors during this process that can lead to delays or reductions in benefits. Recognizing these mistakes can help ensure a smoother submission.

One common mistake is incomplete information. Applicants often leave out critical fields, such as income sources or monthly expenses. Omitting any financial details can raise red flags and result in a request for more information, delaying the processing time.

Another frequent error is providing inaccurate income figures. Some individuals miscalculate their monthly income, either by forgetting to account for all sources or by misreporting figures based on outdated information. This discrepancy can have a significant impact on eligibility and benefit amounts.

Some applicants neglect to include necessary documentation. Supporting documents such as pay stubs, bank statements, or additional income sources must accompany the form. Without these attachments, the application may be considered incomplete.

Inaccurate numbers can also surface when individuals fail to update their financial status. People’s financial conditions can change, and reporting outdated information can lead to incorrect eligibility determinations. Regularly checking and updating financial details is essential.

Individuals might also mistake spousal income as irrelevant, not realizing that it can affect their financial assessment. In communities where married couples combine finances, failing to report a spouse's income can distort the overall picture, leading to errors.

Another mistake is not tracking monthly expenses accurately. Applicants sometimes estimate costs or forget recurring expenses, such as insurance or credit card payments. Underestimating expenses can artificially inflate perceived financial health, resulting in a potential denial of benefits.

Some veterans neglect to sign the form. A missing signature can prevent the form from being officially recognized, causing delays in processing or requiring a complete resubmission.

Lastly, failing to review the completed form can lead to overlooked errors. Taking the time to double-check the form before submission can help catch mistakes, ensuring that all information is accurate and complete.

Ensuring correctness during the completion of the VA 5655 form is vital. By avoiding these common pitfalls, veterans can enhance their chances of receiving timely and adequate benefits.

Documents used along the form

The VA 5655 form, also known as the Financial Status Report, is often part of a broader process when dealing with VA benefits. Other forms and documents frequently accompany it. Understanding these documents can help ensure a smooth and efficient experience in managing your VA benefits.

  • VA Form 21-526EZ: This form is used to apply for veterans' disability compensation. It provides necessary information about your service and any disabilities you may have, serving as a foundational document in the benefits application process.
  • VA Form 21-527EZ: This form allows you to apply for improved pension benefits. It captures details about your financial situation, which is crucial for determining eligibility for pension benefits.
  • VA Form 21-4138: Commonly known as a Statement in Support of Claim, this form allows you to provide additional information to support your application for benefits. You can explain circumstances or details that other forms may not fully capture.
  • VA Form 21-0958: This Notice of Disagreement is filed when you disagree with a decision made by the VA regarding your claim. It initiates the appeals process and is essential for those seeking a review of their case.

Each of these documents serves a specific purpose in the process of obtaining or managing your VA benefits. Having them ready can make the submission process more efficient and provide necessary support to your claims or applications.

Similar forms

The VA Form 5655, also known as the Financial Status Report, plays a significant role in assessing a veteran’s financial circumstances. There are several other documents that serve similar functions in evaluating financial status or eligibility for assistance. Below are four such documents:

  • VA Form 21-4176 - This form is utilized for evaluating a veteran's claim for disability benefits. Similar to the VA 5655, this form requires a detailed account of income, assets, and monthly expenses to determine eligibility for benefits.
  • VA Form 10-10EZ - The Application for Health Benefits allows veterans to apply for healthcare services. This form gathers financial information, akin to the VA 5655, to assess a veteran's eligibility for VA health care based on income levels.
  • IRS Form 1040 - The individual income tax return collects financial data similar to the VA 5655. Both documents require taxpayers to report income, deductions, and credits, providing a comprehensive overview of financial status.
  • HUD Form 92006 - This form is used by the U.S. Department of Housing and Urban Development for housing assistance programs. It requires applicants to provide current financial information, paralleling the financial assessment aspects of the VA 5655.

Each of these documents seeks to provide a clearer picture of an individual's financial situation to ensure appropriate support and services are offered.

Dos and Don'ts

When filling out the VA 5655 form, it’s important to ensure that your application goes smoothly. Here are some things to keep in mind:

  • Do: Provide accurate information. Double-check every entry to ensure it reflects your current situation.
  • Do: Sign and date the form. Without your signature, the form will be considered incomplete.
  • Do: Use clear and legible handwriting if you're filling it out by hand. This helps avoid misunderstandings.
  • Do: Keep a copy of the completed form for your records. This can be useful in case you need to reference it later.
  • Don’t: Forget to read the instructions carefully. Misunderstanding the requirements can lead to delays.
  • Don’t: Include unnecessary personal information. Only provide what the form specifically asks for.
  • Don’t: Leave any questions unanswered. If a question doesn’t apply to you, indicate that clearly.
  • Don’t: Submit the form without reviewing it. A quick final check can save you from potential issues.

Misconceptions

The VA 5655 form, officially known as the "Financial Status Report," is crucial for veterans seeking assistance. However, several misconceptions surround its purpose and requirements. Clarifying these misunderstandings can facilitate the application process for those who need it. Below are ten common misconceptions about the VA 5655 form.

  1. It's only for low-income veterans. Many believe that only veterans with low incomes need to submit this form. In reality, it is required for various financial assessments regardless of income level.
  2. All veterans must submit the form annually. This is untrue. The requirement to submit the VA 5655 form depends on individual circumstances and the type of financial assistance sought.
  3. Completing the form is overly complicated. While the form may seem daunting at first, it is designed to be straightforward. Clear instructions are available to guide veterans through the process.
  4. Only veterans can fill out the form. Family members or authorized representatives can assist in completing the VA 5655 form, especially if the veteran has difficulties managing their finances.
  5. The form only captures current financial status. This form not only collects present financial data but also helps assess future financial needs for various programs.
  6. Submitting the form guarantees assistance. While the VA 5655 is a step toward receiving help, it does not guarantee approval or assistance. Each case is evaluated individually.
  7. Once submitted, the form cannot be updated. Veterans can and should update the VA 5655 form as their financial status changes.
  8. The VA processes the form immediately. Although many hope for quick results, processing times can vary significantly based on various factors, including the volume of applications.
  9. Only specific programs require this form. The VA 5655 may be necessary for various types of benefits, including those related to disability compensation, pension, and other support services.
  10. There is no assistance for completing the form. Many organizations, including veteran service organizations, are available to help veterans and their families complete the VA 5655 form accurately.

Understanding these misconceptions can pave the way for a smoother application process. By remaining informed, veterans can better navigate the benefits available to them.

Key takeaways

Filling out the VA 5655 form can seem daunting, but keeping a few key points in mind can simplify the process. Here are some essential takeaways:

  • The VA 5655 form is used to assess your financial situation when applying for VA benefits.
  • Ensure all sections are completed with accurate and up-to-date information.
  • Be prepared to provide documentation that supports your financial claims.
  • Review your form carefully before submission to avoid mistakes that could delay processing.
  • Submit the form to the appropriate VA office based on your location and situation.
  • Keep a copy of the completed form for your records, as it may be needed for future reference.

By following these tips, you can effectively fill out and use the VA 5655 form for your financial assessments.