VA Form 5655 Form

A Financial Status Report is a document also referred to as VA Form 5655 by the Department of Veterans Affairs. This document supplies the VA with details regarding a veteran’s financial status. A Financial Status Report is most often used to determine the eligibility of a veteran for benefits through the VA. Some of these benefits include debt exemptions, payment plans and compromise offers to reconcile debt. This form collects personal information from the veteran, such as his or her name, social security number, and contact information. In addition, applicants will need to provide a detailed account of their finances, including the employment history for themselves and their spouses, along with information on their income and expenses.

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What is a VA Form 5655?

A VA Form 5655 is used by the Department of Veterans Affairs in the United States. This form is known as a Financial Status Report. The form is used to supply the VA with information regarding your current finances and financial situation. This form is typically requested in order to determine eligibility for various benefits through the VA, such as debt exemptions, payment plans, or compromise offers.
Personal data will be needed in the first section. This includes name, social security number, and address. Employment history for the applicant and their spouse will also be necessary. The next sections will detail finances, including income and expenses. This information is what the Department of Veterans Affairs will use to determine eligibility for benefits. Be sure to fill in each section completely and accurately.

Most Common Uses

A VA Form 5655 is commonly used to supply your financial information to the VA.  The VA will use this information to determine whether you are eligible for certain benefits.

Components of a VA Form 5655

A VA 5655 form contains the following sections:

  • Personal Data
  • Income
  • Expenses
  • Discretionary Income
  • Assets
  • Installment Contracts and Other Debts
  • Additional Data
  • Applicant Certifications

Privacy Act Information

The information that is provided is used to determine if you are eligible for waiver of a debt, for the acceptance of a compromise offer or for a payment plan. 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 used to collect money owed to the VA.
The form's OMB Approved No. is 2900-0165.  The respondent burden estimate for the form is 1 hour.

Sample VA Form 5655

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Sample VA Form 5655

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