Create va form in minutes using a fillable PDF editor. Fill va form va instantly, download blank or editable online. Sign , fax and printable from PC, iPad, tablet or mobile. No software. Try Now!. VA Form , Financial Status Report, is used to determine eligibility for waiver of collection, for the acceptance of a compromise offer or for a payment plan.

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If you fail to make a payment on your debt before it reaches one hundred twenty days delinquent, days from initial billing statement dateaccounts without VA benefits available for offset will automatically transfer to the Department of the Treasury Cross-Servicing Program.

If you make a payment online it will be applied to fotm outstanding balance not at Treasury. What are your options if you are unable to pay your full copay charges? Information about the overpayment claim itself will be filed with different forms, depending on the circumstances. Any information provided by you.

Fill Out Your VA 5655 PDF in Seconds with PDFSimpli.

Just 5565 a PDF to get started! Please read before printing. Sometimes, the debt accrues because the claimant either accidentally or purposefully withheld information that would affect their benefits.

These cookies only collect fa data when you opt in to the PDF editor. Your health care services fprm continue without interruption regardless of whether your bill is referred to Treasury. In 24B, you should mark the amount you can reasonably pay toward your incurred debt on a monthly basis. Bureau, State Veterans Cemetery. Your balance is considered delinquent if it remains unpaid after the balance due date on your initial billing statement, which is typically thirty 30 days after the statement date.

The VA will either want a lump sum of the payment or payments made over time, possibly including interest rates. Because the report often coincides with benefits claims, repayment problems, and collections, this might not be the only report you need to file.


You can continue to make payments on any bill that has not been referred to Treasury.

Get and Sign VA Form 5655 2009-2018

There are multiple options available to help make paying your current copay charges more affordable, or to eliminate them. Section V is for your assets, including your cash in the bank and on hand, your vehicles, savings bonds, and any real estate you own.

Type or print all entries. If your gross household income has decreased from the previous income year, you may be eligible for a Hardship Determination which provides future exemption from medical and hospital care copays for a determined period of time. Waiver, Compromise, Payment Plan or Other.

When does your debt become delinquent? Why is the VA referring your delinquent debt to the Department of the Treasury? Financial Status Report Template.

What are your options if your household income has decreased and you will be unable to pay future copay charges?

For example, a claimant might not mention that one of their dependent children had reached the age of 18 and moved out of the house. VA may not conduct or sponsor, and respondent forn not required to respond to this collection of information unless it displays a valid OMB.

What type of application are you filing?

This piece of paperwork reflects your financial status. Generally speaking, this form is filled out by the claimant. Bureau, State Veterans Home – Boise. The responses you submit are confidential and protected from unauthorized disclosure by 38 U. Bureau, State Veterans Home – Lewiston.

This includes the type of job and its income. The routine uses for which VA may disclose. To pay a bill that has been referred to Treasury, contact Debt Management Services toll free at between 8: Both the spouse and the claimant must sign the form to verify that all of ga information is accurate.

If no additional debt exists with the VA, the payment will be applied as a credit balance and refunded after 60 days, unless a refund is requested sooner. Indicate your proposed monthly payment amount in paragraph 1A. VA systems of records and alterations to the systems are published in the Federal Register.


For the most part, this form is used if a person is meant to repay the VA, for, they do not have the financial capacity to do so.

If Federal agencies are not successful at collecting a debt, they are required under the Digital Accountability and Transparency Act DATA of to for eligible delinquent non-tax debt to TOP for debt collection action within days. You will incur collection fees from Treasury based upon a percentage of your outstanding bill s and length of time outstanding.

You have the right to request a hearing in connection with your request for a waiver. This law centralized the government wide collection of delinquent non-tax debt and gave the Department of the Treasury significant forrm responsibilities in this area. You also have the right to request a waiver of part or all of your debt. Our software makes quick work of file conversion from your PDF. What happens once your bill becomes delinquent? Since the VA believed that child was still in the household, the benefits payments would reflect that.

Debt – Office of Veterans Affairs – Valencia College

You also have the right to request a compromise. However, if the VA has any questions, they may ask for these documents later.

Quarterly Financial Status Report Template. If you have comments regarding. Section I is related to your personal data.

To request a hardship determination, send a letter explaining any financial hardship these charges will cause you and a completed Request for Hardship Determination VA Form HS.