Form CMS-379 Financial Statement of Debtor

Form Approved
OMB No. 0938-0270

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Financial Statement of Debtor
(Submitted for Government Action on Claims Due the United States)
(NOTE: Use additional sheets where space on this form is insufficient or continue on reverse side of pages.)

Authority for the solicitation of the requested information is one or more of the following: 42 CFR 405.376; 4 CFR 101, et.seq.; 31 U.S.C. 951,
et seq.
The principal purpose for gathering this information is to evaluate your capacity to pay the Government’s claim against you. Disclosure of the
information is voluntary. If the requested information is not furnished, the Government will pursue immediate and full payment of its claim
against you.
1. Name (debtor)

2. Birth Date (mo., day, yr.)

3. Home Address

4. Phone No.

5. Name of Spouse (give address if different from yours)

6. Date of Birth (mo., day, yr.)

Debtor Employment Data
7. Occupation

8. How Long in Present Employment?

9. Present Employer’s Name

Address

Phone No.

10. Other Employment—Within Last 3 Years
Employer’s Name

Address

Phone No.

Employment
Dates

11. Present Monthly Income
Salary or Wages $

Other (state source) $

Commissions $

Total $

Spouse’s Employment Data
12. Occupation

13. How Long in Present Employment?

14. Spouse’s Present Employer’s Name Address

Phone No.

15. Other Employment—Within Last 3 Years
Employer’s Name

Address

Phone No.

Employment
Dates

16. Present Monthly Income
Commissions $

Salary or Wages $

Other (state source) $

Total $

Dependents
17. Total
Number

Relationship

Age

Relationship

Age

Relationship

Age

18. Total Monthly Income of
Dependents (except spouse)
$ _________________________________

Form CMS-379 (07/07) EF 07/2007

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Financial Data
19. For What Period Did You Last
File a Federal Income Tax Return

20. Where Filed

21. Amount of Gross Income
Reported

22. Fixed Monthly Expenses
Rent

Food

Utilities

Debt Repayments (Including installments)

Other (specify)

Interest

Total Fixed Monthly Charges

23. Loans Payable
Owed To

Original
Amount

Purpose & Date of Loan

Present
Balance

24. Assets and Liabilities
(Fair market value)

Assets
Cash

$ ___________________

Checking Accounts (show location)
________________________________________
________________________________________

___________________
___________________

Savings Accounts (show location)
________________________________________
________________________________________

___________________
___________________

Motor Vehicles
Year
Make/License No.
________________________________________
________________________________________

___________________
___________________

Debts Owed to You (give name of debtor)
________________________________________
________________________________________

___________________
___________________

Bills Owed (grocery, doctor, lawyer, etc.)

$ ___________________

Installment Debt (car, furniture, clothing, etc.)

___________________

Taxes Owed

___________________

Income
Other (itemize)
___________________________
___________________________

___________________
___________________

Loans Payable (to banks, finance company, etc.) ___________________
Judgments You Owe

___________________

Real Estate Mortgages

____________

Other Debts (itemize)

Judgments Owed to You
___________________________
___________________________

___________________
___________________

Stocks, Bonds and Other Securities (itemize)
___________________________
___________________________
___________________________
___________________________

___________________
___________________
___________________
___________________

Household Furniture and Goods
Items Used In Trade or Business
Other Personal Property (itemize)
___________________________
___________________________

___________________
___________________

Real Estate
___________________________
___________________________
___________________________

___________________
___________________
___________________

___________________________
___________________________
___________________________
___________________________
___________________________
___________________________

___________________
___________________
___________________
___________________
___________________
___________________

___________________
___________________

Total Assets $ _________________
_________________

Form CMS-379 (07/07) EF 07/2007

Liabilities

_________________
Total Liabilities $ _________________

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25. Real Estate Owned
Address

How Owned (jointly,
individually, etc.)

Date
Acquired

Cost

Unpaid Amount
of Mortgage

26. Real Estate Being Purchased Under Contract
Name of Seller

Address
Contract Price

Principal Amount Still Owing Next Cash Payment Due (date)

Amount (of next payment due)

27. Life Insurance Policies
Company

Face Amount

Cash Surrender Value

Outstanding Loans

28. All Real and Personal Property Owned by Spouse and Dependents Valued in Excess of $200 (List each item separately)

29. All Transfers of Property Including Cash (by loan, gift, sale, etc.) That You Have Made Within the Last 3 Years (items of $300 or over)
Date

Amount

Property Transferred

To Whom

30. Are you a party in any lawsuit now pending?

■ Yes, give details below

■ No

31. Are you a trustee, executor, or administrator?

■ Yes, give details below

■ No

32. Is anyone holding any moneys on your behalf?

■ Yes, give details below

■ No

Form CMS-379 (07/07) EF 07/2007

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33. Is there any likelihood you will receive an inheritance?

■ Yes, from whom?

■ No

34. Do you receive, or under any circumstances, expect to receive benefits, from any established trust, from a claim for compensation or
damages, or from a contingent or future interest in property of any kind?
■ Yes, explain below
■ No

With knowledge of the penalties for false statements provided by 18 United States Code 1001 ($10,000 fine and/or 5 years imprisonment) and
with knowledge that this financial statement is submitted by me to affect action by the Department of Health and Human Services, I certify
that I believe the above statement is true and that it is a complete statement of all my income and assets, real and personal, whether held in
my name or by any other.

Date

Signature

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0270. The time required to complete this information collection is estimated to
average 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Form CMS-379 (07/07) EF 07/2007

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