VA · Official form

VA Form 5655: Financial Status Report

VA Form 5655 is the Financial Status Report the VA uses to understand your income, expenses, assets, and debts when you ask for relief on money you owe the VA.

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What is VA Form 5655?

VA Form 5655, Financial Status Report, is how you show the VA your full financial picture when you request help with a VA debt, such as a benefit overpayment or health care copay balance. The form asks for your employment history, monthly income, average monthly living expenses, assets, and other installment debts, and it supports requests for a waiver of the debt, a compromise offer, or an extended monthly payment plan.

The VA also offers an online version of the Financial Status Report on VA.gov, so you can submit the same information without mailing a paper form. Whichever route you use, the VA reviews the report to decide whether collecting the debt would cause financial hardship and what repayment terms are reasonable.

Who files VA Form 5655?

Veterans asking the VA to waive all or part of a benefit overpayment debt
Veterans requesting a repayment plan longer than the VA's standard terms
People making a compromise offer to settle a VA debt for less than the full amount
Beneficiaries responding to a VA debt letter that asks for a Financial Status Report

How to fill out VA Form 5655

Gather recent pay statements, benefit award letters, and your monthly bills so the amounts you report are accurate.
Complete the personal data and employment sections for yourself and, where asked, your spouse.
List your monthly income, average monthly expenses, assets, and installment contracts or other debts; the totals should reflect your real month-to-month situation.
Explain what you are asking for, such as a waiver, compromise, or monthly payment amount you can afford, then sign and date the form.
Submit the report online through the VA.gov Financial Status Report tool, or mail it to the address shown in your VA debt letter, since the correct office depends on the type of debt.

Worth knowing: Where the paper form goes depends on the debt: benefit debts and health care copay debts are handled by different VA offices. Use the address in your debt letter, or submit online at va.gov.

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These are the form's own fields, in the order they appear on the pages. Fill in what you know; anything left blank stays a fillable field in the PDF, so you can finish it in any PDF reader. Nothing you type here is sent to VA.

Page 1 53 fields

1. social security number

2. FILE NUMBER

(Type or print all entries. If more space is needed for any item, continue under Section 7, Additional Data, Item 36 or attach separate

Read the Privacy Act Notice and Respondent Burden above. SECTION 1 - 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 NUMBER (Include Area Code)

7. DATE OF BIRTH (M M - D D - Y Y Y Y)

8. MARITAL STATUS "married" radio button.

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 11. YOUR EMPLOYMENT EXPERIENCE

11. Line 1: Enter Date, From to Present Time

11. NAME AND ADDRESS OF EMPLOYER line 1 of 2

11. KIND OF JOB. (Prior to current job.)

11. Line 2: Date, From. Enter 2-digit month and 4-digit year.

11. Date to. line 2

11. NAME AND ADDRESS OF EMPLOYER line 2 of 2

KIND OF JOB 12. YOUR SPOUSE'S EMPLOYMENT. line 1 of 2.

12. Line 1 of 2: Date From to Present Time

12. NAME AND ADDRESS OF EMPLOYER line 1 of 2

KIND OF JOB. line 2 of 2.

12. Line 2 of 2: Date From

12. Date, To, line 2

12. NAME AND ADDRESS OF EMPLOYER line 2 of 2

SECTION 2 - INCOME AVERAGE MONTHLY INCOME 13. MONTHLY GROSS SALARY (Before payroll deductions) for Self

13. MONTHLY GROSS SALARY (Before payroll deductions) for Spouse

14. PAYROLL DEDUCTIONS. A. FEDERAL, STATE AND LOCAL INCOME TAXES for Self

A. FEDERAL, STATE AND LOCAL INCOME TAXES for Spouse

B. Retirement - Self

B. Retirement - Spouse

C. SOCIAL SECURITY - for SELF

C. SOCIAL SECURITY - for spouse

D. Other (Specify)

D. Other - Self

D. Other - Spouse

E. TOTAL DEDUCTIONS (Items 14 A through 14 D) for Self.

E. TOTAL DEDUCTIONS (Items 14 A through 14 D) for Spouse.

15. NET TAKE HOME PAY (Subtract Item 14 E from Item 13) Self

15. NET TAKE HOME PAY (Subtract Item 14 E from Item 13) Spouse

16. VA BENEFITS, Social Security, OR OTHER INCOME (Specify)

16. V A BENEFITS, Social Security, OR OTHER INCOME - Self

16. V A BENEFITS, Social Security, OR OTHER INCOME - Spouse

17. TOTAL MONTHLY NET INCOME (Item 15 plus Item 16) - Self

17. TOTAL MONTHLY NET INCOME (Item 15 plus Item 16) - Spouse

SECTION 3 - EXPENSES AVERAGE MONTHLY EXPENSES 18. RENT OR MORTGAGE PAYMENT

19. Food

20. Utilities and Heat

21. OTHER LIVING EXPENSES (specify)

21. Other Living Expenses amount

22. MONTHLY PAYMENTS ON INSTALLMENT CONTRACTS AND OTHER DEBTS (Include amount from Section 6, Line 34 I - Column E.)

23. TOTAL MONTHLY EXPENSES

SECTION 4 - DISCRETIONARY INCOME 24 A. NET MONTHLY INCOME LESS EXPENSES (Item 17 less Item 23)

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

Page 2 82 fields

SECTION 5 - ASSETS 25. CASH IN BANK (Checking and savings accounts, building and loan accounts, etcetera)

26. CASH ON HAND

27. AUTOMOBILES (Resale value) Make. line 1 OF 3.

Year line 1 of 3

Model. line 1 of 3

AUTOMOBILES Resale value line 1 of 3

Make. line 2 OF 3.

Year line 2 of 3

Model. line 2 of 3

AUTOMOBILES Resale value line 2 of 3

Make. line 3 OF 3.

Year line 3 of 3

Model. line 3 of 3

AUTOMOBILES Resale value line 3 of 3

28. TRAILERS, BOATS, CAMPERS (Resale value)

29. US SAVINGS BONDS (Current Value)

30. STOCKS AND OTHER BONDS (Current Value)

31. REAL ESTATE OWNED (Resale value)

32. OTHER ASSETS (Specify below) line 1 of 3.

OTHER ASSETS VALUE. line 1 OF 3.

OTHER ASSETS line 2 of 3.

OTHER ASSETS VALUE. line 2 OF 3.

OTHER ASSETS line 3 of 3.

OTHER ASSETS VALUE. line 3 OF 3.

33. TOTAL ASSETS

SECTION 6 - INSTALLMENT CONTRACTS AND OTHER DEBTS Read NOTE above. 34 A. NAME AND ADDRESS OF CREDITOR

34 A. DATE AND PURPOSE OF DEBT

34 A. ORIGINAL AMOUNT OF DEBT

34 A. UNPAID BALANCE

34 A. AMOUNT DUE MONTHLY

34 A. AMOUNT PAST DUE

34 b. NAME AND ADDRESS OF CREDITOR

34 b. DATE AND PURPOSE OF DEBT

34 B. ORIGINAL AMOUNT OF DEBT

34 B. UNPAID BALANCE

34 B. AMOUNT DUE MONTHLY

34 B. AMOUNT PAST DUE

34 c. NAME AND ADDRESS OF CREDITOR

34 c. DATE AND PURPOSE OF DEBT

34 C. ORIGINAL AMOUNT OF DEBT

34 C. UNPAID BALANCE

34 C. AMOUNT DUE MONTHLY

34 C. AMOUNT PAST DUE

34 d. NAME AND ADDRESS OF CREDITOR

34 d. DATE AND PURPOSE OF DEBT

34 D. ORIGINAL AMOUNT OF DEBT

34 D. UNPAID BALANCE

34 D. AMOUNT DUE MONTHLY

34 D. AMOUNT PAST DUE

34 e. NAME AND ADDRESS OF CREDITOR

34 e. DATE AND PURPOSE OF DEBT

34 E. ORIGINAL AMOUNT OF DEBT

34 E. UNPAID BALANCE

34 E. AMOUNT DUE MONTHLY

34 E. AMOUNT PAST DUE

34 f. NAME AND ADDRESS OF CREDITOR

34 f. DATE AND PURPOSE OF DEBT

34 F. ORIGINAL AMOUNT OF DEBT

34 F. UNPAID BALANCE

34 F. Enter AMOUNT DUE MONTHLY

34 F. AMOUNT PAST DUE

34 g. NAME AND ADDRESS OF CREDITOR

34 g. DATE AND PURPOSE OF DEBT

34 G. ORIGINAL AMOUNT OF DEBT

34 G. UNPAID BALANCE

34 G. AMOUNT DUE MONTHLY

34 g AMOUNT PAST DUE (If any)

Item 34h. NAME AND ADDRESS OF CREDITOR

Item 34h. DATE AND PURPOSE OF DEBT

Item 34H. ORIGINAL AMOUNT OF DEBT

ITEM 34H. UNPAID BALANCE

ITEM 34H. Enter AMOUNT DUE MONTHLY

ITEM 34H. Enter AMOUNT PAST DUE

34 i. TOTAL ORIGINAL AMOUNT OF DEBT

34 i. TOTAL UNPAID BALANCE

34 i. TOTAL AMOUNT DUE MONTHLY

34 i. TOTAL AMOUNT PAST DUE See NOTE below

SECTION 7 - ADDITIONAL DATA 35. A. HAVE YOU EVER BEEN ADJUDICATED BANKRUPT? IF SO AND V. A. OR A MORTGAGE COMPANY WAS INVOLVED, PLEASE SEND

35 B. DATE DISCHARGED FROM BANKRUPTCY.

35 C. LOCATION OF COURT

35 D. DOCKET NUMBER, IF KNOWN

36. USE THIS SPACE AND ADDITIONAL SHEETS, IF NECESSARY, TO SUPPLY ANY PERTINENT INFORMATION AND TO CONTINUE YOUR ANSWER TO PREVIOUS ITEM

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Frequently asked questions

When does the VA ask for a Financial Status Report?

Typically after it notifies you of a debt, if you want anything other than paying the balance in full right away. Waivers, compromise offers, and longer payment plans all generally require a completed VA Form 5655 so the VA can evaluate hardship.

Is there a deadline to request a waiver?

Yes, waiver requests are time limited, and the clock generally starts with the date of your debt notification letter. Check your letter and the current guidance on va.gov, and submit the form as soon as you can rather than waiting.

Can I submit VA Form 5655 online instead of on paper?

Yes. The VA offers the Financial Status Report as an online tool on VA.gov, which asks the same questions as the paper form. Either version is acceptable; the online route avoids mailing time.

VA Form 5655: Financial Status Report

What is VA Form 5655?

Who files VA Form 5655?

How to fill out VA Form 5655

Quick fill VA Form 5655 on this page

Frequently asked questions

Related forms

VA Form 21P-527EZ, Application for Veterans Pension

VA Form 10-10EZR: Health Benefits Update Form

VA Form 21-4138: Statement in Support of Claim