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COMPROMISING CLAIMS WORKSHEET

Name: __________________________________ Claim Number: ___________________________ Claim amount: ____________________________ Claim Balance: ___________________________

To ensure that we properly consider your financial circumstances, please provide documentation of your household's income and expenses. Please provide a copy of recent pay statement or other documentation

Monthly Amount of Income for All Household Members:

Earnings: $__________________ Social Security: $_______________ Alimony: $__________________ Child Support: $_______________ Other Income: $__________________ Pensions/retirement: $_______________

Resources:

Checking Account $____________________ Savings: Account $____________________ Market value of stocks, bonds, mutual funds and other investments: $____________________

Monthly Expenses:

Rent/ Mortgage: $_________________ Electricity: $_________________ Gas: $_________________ Water/ Sewer: $_________________ Telephone: $_________________ Other Utilities: $_________________ Health Insurance: $_________________ Other Medical: $_________________ Alimony/Child support: $_________________

_______________________________________ _______________________________________

Signature Date

Agency Use Only

Ability to Pay: 1. Total monthly income: $_____________ Household size when claim established: 2. 10 % of resources: + $_____________ _____________ 3. Combined income/resources: = $_____________ 200% Poverty Level for household 4. Total expenses: - $_____________ _____________ 5. Available funds for payment $_____________ Referred to TOP? Yes  No 

6. 10% of available funds (line 5) $_____________ 7. X 3 years or 36 months $_____________ 8. Claims balance: $_____________ 9. Amount to be paid (line 7): - $_____________ 10. Amount to be compromised: $_____________

 Compromise Approved  Compromise Denied Explanation: ______________________________________________________________________ _______________________________________ _______________________________________

Signature Date

032-03-0572-00-eng (1/13)