DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0270 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) 3. Home Address 5. Name of Spouse (give address if different from yours) 2. Birth Date (mo., day, yr.) 4. Phone No. 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 $ Commissions $ Other (state source) $ Total $ Spouse's Employment Data 12. Occupation 14. Spouse's Present Employer's Name Address 15. Other Employment--Within Last 3 Years Employer's Name Address Phone No. Employment Dates 13. How Long in Present Employment? Phone No. 16. Present Monthly Income Salary or Wages $ Commissions $ 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 Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com 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 Debt Repayments (Including installments) Total Fixed Monthly Charges Food Other (specify) Utilities Interest 23. Loans Payable Owed To Purpose & Date of Loan Original Amount Present Balance 24. Assets and Liabilities Assets Cash Checking Accounts (show location) ________________________________________ ________________________________________ Savings Accounts (show location) ________________________________________ ________________________________________ Motor Vehicles Year Make/License No. ________________________________________ ________________________________________ Debts Owed to You (give name of debtor) ________________________________________ ________________________________________ 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 ___________________________ ___________________________ ___________________________ (Fair market value) $ ___________________ ___________________ ___________________ Liabilities 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) ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ Total Assets $ _________________ _________________ Total Liabilities $ _________________ _________________ Form CMS-379 (07/07) EF 07/2007 Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com 25. Real Estate Owned Address How Owned (jointly, individually, etc.) Date Acquired Cost Unpaid Amount of Mortgage 26. Real Estate Being Purchased Under Contract Address Contract Price Principal Amount Still Owing Next Cash Payment Due (date) Name of Seller 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? s Yes, give details below s No 31. Are you a trustee, executor, or administrator? s Yes, give details below s No 32. Is anyone holding any moneys on your behalf? s Yes, give details below s No Form CMS-379 (07/07) EF 07/2007 Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com 33. Is there any likelihood you will receive an inheritance? s Yes, from whom? s 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? s Yes, explain below s 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 c