AMEDDApplicantWorksheet-July2012-3.doc

Have you failed to file or pay federal state or other

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have you failed to file or pay Federal, state, or other taxes when required by law or ordinance? Date you failed to file or pay your Federal, State, or other taxes (dd-MMM-yyyy): Date satisfied (dd-MMM-yyyy): Amount of taxes: Did you Fail to File, Pay, or Both? Type of Taxes: Federal, State, or Other Agency to which you failed to pay: Reason for failure to file/pay: Description of actions taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.) If you have not taken any action(s) provide explanation: 4. In the past seven (7) years have you been counseled, warned, or disciplined for violating the terms of agreement for a travel or credit card provided by your employer? Date of your counseling, warning, or disciplinary action: Name of Agency or Company or Employer: Street City State Zip Country Amount of Violation:$ Reason(s) for the counseling, warning, or disciplinary action: Description of action(s) taken to rectify this situation. If not taken any action(s), provide explanation: 5. Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to resolve your financial difficulties? Explanation of Credit Counseling: Name of the Credit Counseling Organization or Resource: City State Phone #: Ext: Best time to contact: As a result of this counseling, provide a description on any actions(s) you have taken to resolve your financial difficulties. If you have not taken any action(s), provide explanation 6. Other than previously listed, have any of the following happened to you? (You will be asked to provide details about each financial obligation that pertains to the items identified below). In the past seven (7) years , you have been delinquent on alimony or child support payments. In the past seven (7) years , you had a judgement entered against you. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor.). In the past seven (7) years , you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor). You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are cosigner or guarantor). 50
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7. Other than previously listed, have any of the following happened? In the past seven (7) years , you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations for which you where the sole debtor as well as those where you were a cosigner or guarantor) In the past seven (7) years , you defaulted on any type of loan? (Include financial obligations for which you where the sole debtor as well as those where you were a cosigner or guarantor) In the past seven (7) years , you had bills or debts turned over to a collection agency? (Include
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