FINANCIAL STATEMENT - REMISSION OF INDEBTDNESS

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FINANCIAL STATEMENT - REMISSION OF INDEBTEDNESS (7220)

NAVMC 11082 (Rev. 5-97) (EF)

PRIVACY ACT STATEMENT

The Privacy Act Statement for information on this

form is contained on NAVMC form11000

Privacy Act Statement for Marine CorpsPersonnel

and Pay Records.

(Previous editions are obsolete and will not be used)

NAME (Last,First, MI)

SSN

GRADE

MOS (NO. and Title)

TOTAL SERVICE

(YR./MO./DA)

TOTAL DEBT IS/WAS

AMT. COLLECTED

ENLISTMENT EXPIRES

BALANCE FOR REMISSION

CONSIDERATION

DEPENDENTS

RELATIONSHIP

AGE

NAME

PERCENT OF SUPPORT

MONTHLY INCOME AND EXPRESS

(DO NOT list spouse's exspense incident to his/her employment. Enter information

concerning spouse's employment under the heading "SPOUSE'S INCOME", below.)

MONTHLY EXPENSES

MONTHLY INCOME

BASIC PAY

FEDERAL INCOME TAX WITHHELD

BASIC ALLOWANCE FOR QUARTERS (BAQ)

STATE INCOME TAX WITHHELD

BASIC ALLOWANCE FOR SUBSISTENCE/COMRATS

FICA TAX

CLOTHING ALLOWANCE

RENT

FAMILY SEPARATION ALLOWANCE (FSA)

UTILITIES*

VARIABLE HOUSING ALLOWANCE (VHA)

OTHER (Specify)

TELEPHONE

FOOD

CLOTHING

INSURANCE*

TOTAL

MONTHLY INSTALLMENT PAYMENTS

ITEM

EXPIRES

HOUSE

FURNITURE

OTHER (Specify)

TOTAL

Reset Form

AMOUNT

SCHOOL*

MEDICAL/DENTAL*

COURTS MARTIAL OR ARTICLE 15

FORFEITURES - EXPIRES:

CHILD SUPPORT, ALIMONY OR SEPARATE

MAINTENANCE (Furnish copy of court order or decree.)

OTHER (Specify)

CAR

REMARKS

CAR EXPENSES (Operating)

TOTAL

*ITEMIZE/EXPLAIN AS APPROPRIATE. USE SEPARATE SHEET IF

NECESSARY.

Adobe Designer 8.0

NAVMC 11082 (Rev. 5-97) (EF) (BACK)

RECAP OF A MARINE'S TOTAL MONTHLY INCOME

MARINE'S TOTAL MONTHLY GROSS INCOME (PAY AND ALLOWANCES)

TOTAL MONTHLY INSTALLMENT PAYMENTS

TOTAL MONTHLY EXPENSES

TOTAL MONTHLY OBLIGATIONS (INSTALLMENT PAYMENTS AND EXPENSES

MARINE'S NET INCOME (INCOME LESS TOTAL OBLIGATIONS FROM PAY AND ALLOWANCES)

SPOUSE'S INCOME

SPOUSE'S MONTHLY GROSS INCOME

SPOUSE'S OTHER MONTHLY GROSS INCOME

LESS EXPENSES INCIDENT TO EMPLOYMENT

LESS EXPENSES INCIDENT TO THE

OPERATION OF A PRIVATE BUSINESS OR

OTHER OUTSIDE INCOME.

FITW

SITW

FICA

CAR MAINTENANCE & OPERATION

(Itemize and/or explain as appropriate. Use separate

sheet if necessary.)

OTHER TRANSPORTATION EXPENSES

CAR PAYMENT

CHILD CARE

OTHER (Specify)

NET AMOUNT OF OTHER MONTHLY INCOME

RECAP OF TOTAL MONTHLY FAMILY INCOME

MARINE'S NET INCOME

SPOUSE'S NET INCOME

TOTAL EXPENSES

SPOUSE'S NET INCOME (INCOME LESS EXPENSES

OTHER NET INCOME

DIFFERENCE BETWEEN TOTAL MONTHLY INCOME

AND EXPENSES FOR FAMILY

ASSETS

SHOW PRESENT VALUE OF AND EQUITY IN ALL ASSETS OTHER THAN HOUSEHOLD GOODS AND CLOTHING, INCLUDING BUT NOT

LIMITED TO SAVINGS AND CHECKING ACCOUNTS, STOCKS AND BINDS, REAL PROPERTY, AUTOMOBILES, BOATS, TRAILER, BUSINESS,

ETC.

CERTIFICATION

I CERTIFY that the information furnished is correct and complete to the best of my knowledge and belief.

SIGNATURE OF MARINE

DATE

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