STATEMENT OF FINANCIAL STATUS - EOS CCA

STATEMENT OF FINANCIAL STATUS

{INFORMATION PROVIDED ON THIS FORM WILL BE HELD CONFIDENTIAL}

The information you provide in the following statement will be used to determine your ability to repay your defaulted loan. It is to your advantage to be as accurate and clear as possible, and explain any unusual expenses. You must enclose a copy of two recent pay stubs (leave and earnings statement) from you and your spouse, as well as any other contributing member of your household. You must provide documentation (copies of bills, receipts, etc.) of expenses you list. You may attach additional pages if needed to document additional expenses or provide explanations.

Do not include monthly payments on credit cards. If, for example, you are making payments on a department store card that you used to purchase clothing, list that payment under "clothing" expenses. If you are paying some of your expenses quarterly or annually, such as automobile insurance or property taxes, calculate what the amount would be on a monthly basis and put that amount in the space provided. Do not leave any item blank. If the answer is zero, write zero.

Your Name: ________________________________________________ (Last, First, Middle, Previous)

Date of Birth:_________________ Social Security Number:________________________

Current Residence Address: _____________________________________________________

City State Zip: ______________________________________________________________

Res. Telephone Number: ___________________________________

Your Present Employer: ________________________________________________________ (If you have multiple employers, please attach a separate sheet)

Date Employed:______________________________________

Employer Address: ____________________________________________________________

Gross Income: $_____________per_____ Net Income: $ _____________per__________

Present Position:_______________________________________________________________

Number of dependents including self (as defined by IRS): ________________

Married ________ Single __________ Divorced _________

Spouse's Name: ______________________________________ (Last, First, Middle)

Social Security Number: __________________________________

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Gross Income: $_____________per_____ Other Contributing Residents _________________________________ _________________________________

Net Income: $ _____________per__________ Social Security Number(s) _______________________ _______________________

Gross Income: $_____________per_____ Net Income: $ _____________per__________

OTHER INCOME (Child Support, Alimony, Interest, Public Assistance, etc.) describe: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

See Last Page For Privacy Act Notice

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Monthly Expenses:

Please provide documentation for all bills pertaining to shelter, utilities, medical expenses, car payments, car insurance, child expenses and any other insurance you many have.

Shelter:Rent/Mortgage (To Whom) ______________________________)$ ________________ (If buying ? Name & Address of Lender)

Second Home Mortgage (To Whom ____________________) $ ________________

Home Insurance

$ ________________

Property Taxes

$ ________________

Other (Describe ____________________________________) $ ________________

Food:

$______________

Utilities: Electric

$______________

Gas

$______________

Water Sewer

$______________

Garbage Pickup

$______________

Basic Telephone

$______________

Other (Describe ________________________________________)$______________

Clothing:

$______________

Medical: Health Insurance Payments Not Deducted From Paycheck

$______________

Medical Bill Payments Not Covered By Insurance

$______________

Other (Describe___________________________________)

$______________

Transportation: Car Payments (To Whom___________________________) $______________

Gas & Oil

$______________

Public Transportation

$______________

Car Insurance

$______________

Other (Describe______________________________________) $______________

Child Expenses: Child Care (Number of Children_____________________) $______________

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Child Support: (Number of Children _____________________)

$______________

Other (Describe______________________________________)

$______________

Other Insurance (Describe___________________________________)

$______________

Assets

All Checking Account Balances (Where Held_______________________) $______________

(Where Held_______________________) $______________

All Savings Account Balances (Where Held_______________________) $______________

(Where Held_______________________) $______________

Home-Current Market Value: $__________,Balance of Note: $_________, $Equity:$_________

Other Property Owned: Type____________ (If Real Estate, Location_____________________)

Current Market Value: $____________, Balance of Note: $___________ Equity: $__________

Auto #1 ? Current Market Value:$__________, Balance of Note:$__________ Equity:$_______ Make__________________________, Year___________________

Auto #2 ? Current Market Value:$__________, Balance of Note:$__________ Equity:$_______ Make__________________________, Year___________________

Stocks, Bonds and Certificates of Deposit ? Current Value:

$______________

Current Cash (Loan) Value of Life Insurance

$______________

Other Accounts Receivable or Asset (Describe_________________________)$_____________

Please sign the declaration below:

I cannot pay my debt in full at this time. Please schedule monthly payments in the amount of $______________, based on my financial statement above.

I declare under the penalties provided by Title 18, Sec. 1001 U.S. Code, the answers and statements contained herein are to the best of knowledge and belief true, correct and complete.

____________________________________________ _________________________

Signature

Date

WARNING: Title 18, Sec. 1001 U.S. Code: "whoever...knowingly and willfully falsifies, conceals or covers up

by any trick, scheme, or devise a material fact, or makes any false, fictitious or fraudulent statements or representation.., shall be fined not more than $10,000.00, or imprisoned not more than five years, or both".

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PRIVACY ACT NOTICE THIS REQUEST IS AUTHORIZED UNDER 31 U.S.C. 3711,20 U.S.C. 1078-6, AND 20 U.S.C. 1095A. YOU ARE NOT REQUIRED TO PROVIDE THIS INFORMATION. IF YOU DO NOT, WE CANNOT DETERMINE YOUR FINANCIAL ABILITY TO REPAY YOUR

STUDENT AID DEBT. THE INFORMATION YOU PROVIDE WILL BE USED TO EVALUATE YOUR ABILITY TO PAY. IT MAY BE DISCLOSED TO GOVERNMENT AGENCIES AND THEIR CONTRACTORS, TO EMPLOYERS, LENDERS, AND OTHERS TO ENFORCE THIS DEBT; TO THIRD PARTIES IN AUDIT, RESEARCH, OR DISPUTE ABOUT THE MANAGEMENT OF THIS DEBT; AND TO PARTIES WITH A RIGHT TO THIS INFORMATION UNDER THE FREEDOM OF INFORMATION ACT OR OTHER

FEDERAL LAW OR WITH YOUR CONSENT. THESE USES ARE EXPLAINED IN NOTICE IN THE STUDENT FINANCIAL ASSISTANCE COLLECTION FILES, NO 18-11-

07; WE WILL SEND A COPY AT YOUR REQUEST.

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