SAMPLE at Form 13.1: Financial Statement (Property and Support Claims)

ONTARIO
Court File Num ber
SAMPLE
at
Form 13.1: Financial Statement
(Property and Support Claims)
sworn/affirmed
(Court office address)
Applicant(s)
Full legal name & address for service — street & number, municipality,
postal code, telephone & fax numbers and e-mail address (if any).
Lawyer’s name & address — street & number, municipality, postal code,
telephone & fax numbers and e-mail address (if any).
Respondent(s)
Full legal name & address for service — street & number, municipality,
postal code, telephone & fax numbers and e-mail address (if any).
Lawyer’s name & address — street & number, municipality, postal code,
telephone & fax numbers and e-mail address (if any).
INSTRUCTIONS
1.
2.
USE THIS FORM IF:
! you are m aking or responding to a claim for property or exclusive possession of the m atrim onial hom e and its
contents; or
! you are m aking or responding to a claim for property or exclusive possession of the m atrim onial hom e and its
contents together with other claim s for relief.
USE FORM 13 INSTEAD OF THIS FORM IF:
! you are m aking or responding to a claim for support but NOT m aking or responding to a claim for property or
exclusive possession of the m atrim onial hom e and its contents.
3.
If you have incom e that is not shown in Part I of the financial statem ent (for example, partnership incom e, dividends,
rental incom e, capital gains or RRSP incom e), you m ust also com plete Schedule A.
4.
If you or the other party has sought a contribution towards special or extraordinary expenses for the child(ren), you
m ust also com plete Schedule B.
NOTE: You must fully and truthfully complete this financial statement, including any applicable schedules. Failure to do so may
result in serious consequences.
1.
M y name is (full legal name)
I live in (municipality & province)
John Smith
Mississauga, Province of Ontario
and I swear/affirm that the follow ing is true:
PART 1: INCOME
2.
I am currently
x
em ployed by (name and address of employer)
ABC Corporation, 123 Corporate Drive, Mississauga, Ontario L7N 4H6
self-em ployed, carrying on business under the nam e of (name and address of business)
unem ployed since (date when last employed)
3.
I attach proof of m y year-to-date incom e from all sources, including m y m ost recent (attach all that are applicable):
x pay cheque stub
social assistance stub
pension stub
workers’ com pensation stub
em ploym ent insurance stub and last Record of Em ploym ent
statem ent of incom e and expenses/ professional activities (for self-em ployed individuals)
other (e.g. a letter from your employer confirming all income received to date this year)
FLR 13.1 (February 1, 2010)
www .D IV O R C E m ate.com
Form 13.1: Financial Statement (Property and
Support Claims)
(Page 2)
Court File Num ber
$95,926.47.
Last year, m y gross incom e from all sources was
(do not subtract any taxes that have been deducted from this income).
4.
5.
x
I am attaching the following required docum ents to this financial statem ent as proof of m y incom e over
the past three years, if they have not already been provided:
!
a copy of m y personal incom e tax returns for each of the past three taxation years, including any m aterials
that were filed with the returns. (Incom e tax returns m ust be served but should NOT be filed in the
continuing record, unless they are filed with a m otion to refrain a driver's license suspension.)
!
a copy of m y notices of assessm ent and any notices of reassessm ent for each of the past three taxation
years;
!
where m y notices of assessm ent and reassessm ent are unavailable for any of the past three taxation
years, an Incom e and Deductions printout from the Canada Revenue Agency for each of those years,
whether or not I filed an incom e tax return.
Note: An Income and Deductions printout is available from Canada Revenue Agency. Please call customer service
at 1-800-959-8281.
OR
I am an Indian within the m eaning of the Indian Act (Canada) and I have chosen not to file incom e tax
returns for the past three years. I am attaching the following proof of incom e for the last three years (list
documents you have provided):
(In this table you must show all of the income that you are currently receiving.)
Income Source
1. Em ploym ent incom e (before deductions)
Amount Received
/M onth
$7,993.87
Estimate your current employment income on a monthly basis.
To convert bi-weekly income to monthly - multiply by 26 and divide by 12
(ie. $3,689.48/bi-weekly x 26 / 12 = $7,993.87)
To convert weekly income to monthly - multiply by 52 and divide by 12
(ie. $1,844.74/week x 52 / 12 = $7,993.87)
REQUIRED: Notices of Assessment and Income Tax Returns for the past 3
years and at least one most recent paystub.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Com m issions, tips and bonuses
Self-em ploym ent incom e
(Monthly am ount before expenses:
)
Em ploym ent Insurance benefits
W orkers’ com pensation benefits
Social assistance incom e (including ODSP paym ents)
Interest and investm ent incom e
Pension incom e (including CPP and OAS)
Spousal support received from a form er spouse/partner
Child Tax Benefits or Tax Rebates (e.g. GST)
Other sources of incom e (e.g. RRSP withdrawals, capital gains) (*attach Schedule A and
divide annual amount by 12)
12. Total monthly income from all sources:
13. Total monthly income X 12 = Total annual income:
$7,993.87
$95,926.44
14. Other Benefits
Provide details of any non-cash benefits that your employer provides to you or are paid for by your business such as medical
insurance coverage, the use of a company car, or room and board.
Item
Details
Yearly M arket Value
Court File Num ber
Form 13.1: Financial Statement (Property and
Support Claims)
(Page 3)
Total
$0.00
PART 2: EXPENSES
Expense
M onthly
Amount
Automatic Deductions
EI prem ium s
Incom e taxes
Em ployee pension contributions
Union dues
SUBTOTAL
Housing
Rent or m ortgage
Property taxes
Property insurance
Public transit, taxis
Gas and oil
Car insurance and license
Repairs and m aintenance
Parking
Car Loan or Lease Paym ents
SUBTOTAL
$176.55
$60.98
$1,900.00
$100.00
$30.00
$2,267.53
SUBTOTAL
$1,500.00
$246.00
$67.00
Heat & Electricity
Telephone
Cell phone
Cable
Internet
SUBTOTAL
$50.00
$1,863.00
$40.00
$200.00
$35.00
$40.00
$50.00
$50.00
$415.00
Household Expenses
Groceries
Household supplies
Meals outside the hom e
Pet care
Laundry and Dry Cleaning
SUBTOTAL
Health
Health insurance prem ium s
Dental expenses
Medicine and drugs
Eye care
SUBTOTAL
$50.00
$20.00
$50.00
$120.00
Clothing
Hair care and beauty
Alcohol and tobacco
$50.00
$30.00
$40.00
Education (specify)
Utilities
W ater
$300.00
$125.00
$100.00
$20.00
$449.00
$994.00
Personal
Condom inium fees
Repairs and m aintenance
SUBTOTAL
$40.00
$90.00
Transportation
Calculate your automatic deductions
from pay on a monthly basis. Your
T4 statement or a recent pay stub will
generally provide such information.
If using your T4 divide the annual
amount by 12.
If using your paystub convert the
amount to monthly (as above).
CPP contributions
Allowances
$400.00
$100.00
$200.00
$40.00
$20.00
$760.00
Entertainm ent/recreation (including
children)
Gifts
SUBTOTAL
$50.00
$75.00
$245.00
Other expenses
Life Insurance prem ium s
RRSP/RESP savings
Vacations
School fees and supplies
Clothing for children
Children’s activities
Sum m er cam p expenses
Debt paym ents
$50.00
$500.00
$200.00
$20.00
$50.00
$200.00
$50.00
$100.00
Support paid for other children
Incom e Tax and Canada Pension Plan
(not deducted from pay)
Other expenses not shown above
(specify)
Childcare Costs
SUBTOTAL
Daycare expense
Babysitting costs
$50.00
$1,170.00
Court File Num ber
Form 13.1: Financial Statement (Property and
Support Claims)
(Page 4)
Total Amount of M onthly Expenses
$7,924.53
$95,094.36
Total Amount of Yearly Expenses
PART 3: OTHER INCOME EARNERS IN THE HOME
Complete this part only if you are making or responding to a claim for undue hardship or spousal support. Check and
complete all sections that apply to your circumstances.
1.
2.
I live alone.
x
I am living with (full legal name of person you are married to or cohabiting with)
Mary Ann Johnson
3.
4.
5.
I/we live with the following other adult(s):
x
I/we have (give number)
My spouse/partner
x
2
of child(ren) who live(s) in the hom e.
works at (place of work or business)
XYZ Corporation
does not work outside the hom e.
6.
My spouse/partner
x
earns (give amount)
$50,000.00
per
year
.
does not earn any incom e.
7.
x
My spouse/partner or other adult residing in the hom e contributes about
month
$1,500.00 per
towards the household expenses.
The following is applicable to Parts 4 and 5:
(a)
List your percentage ownership of the assets or liabilities.
(b)
List the values of your assets or liabilities as of the date of marriage, valuation date and today.
(c)
The valuation date is usually the date of separation.
PART 4: ASSETS IN AND OUT OF ONTARIO
If any sections of Parts 4 to 9 do not apply, do not leave blank, print “NONE” in the section.
The date of m arriage is: (give date)
The valuation date is: (give date)
August 1, 1995
July 1, 2008
The date of com m encem ent of cohabitation is (if different from date of m arriage): (give date)
PART 4(a): LAND
April 1, 1994
Court File Num ber
Form 13.1: Financial Statement (Property and
Support Claims)
(Page 5)
Include any interest in land owned on the dates in each of the columns below, including leasehold interests and mortgages. Show
estimated market value of your interest, but do not deduct encumbrances or costs of disposition; these encumbrances and costs should
be shown under Part 5, “Debts and Other Liabilities”.
•
•
•
List your percentage ownership in all real estate and estimate the value of your interest in the property.
Do not deduct the mortgage. It will be deducted in Part 8.
In the columns under the appropriate dates list the value of your interest in the property. For example if
you estimate the property is worth $300,000.00 you would list:
1)
2)
3)
$300,000.00 if you own 100% of the property
$150,000.00 if you own 50% of the property
$ 90,000.00 if you own 30% of the property
Nature & Type of
Ownership
(Give your percentage
interest where relevant.)
Estimated Market Value of YOUR Interest
Address of Property
Matrimonial Home
(jointly owned - 50%
interest)
123 Maple Lane
Mississauga, Ontario
L5N 4M6
Full estimated value on:
(a) date of marriage $200,000.00
(b) date of separation $300,000.00
(c) today $320,000.00
Cottage
(sole owner - 100%)
456 Oak Lane
Parry Sound, Ontario
N3V 5K7
15. TOTAL VALUE OF LAND
on date of
marriage
$100,000.00
$100,000.00
on valuation date
today
$150,000.00
$160,000.00
$250,000.00
$250,000.00
$400,000.00
$410,000.00
PART 4(b): GENERAL HOUSEHOLD ITEMS AND VEHICLES
Show estimated market value, not the cost of replacement for these items owned on the dates in each of the columns below. Do not deduct
encumbrances or costs of disposition; these encumbrances and costs should be shown under Part 5, "Debts and Other Liabilities".
•
•
•
•
•
Household goods and furniture - put “to be divided” unless the furniture is worth a lot.
Cars, boats, vehicles - list the vehicles you owned and estimate the used resale value of each vehicle on each
date.
Do not list leased vehicles or any other leased items.
Do not list the vehicle if your spouse is the registered owner.
Jewellery, art etc. - estimate the used resale value of jewellery, works of art or other valuable collections.
Court File Num ber
Form 13.1: Financial Statement (Property and
Support Claims)
(Page 6)
Item
Description
Household
goods &
furniture
To be divided
Cars, boats,
vehicles
2008 Toyota Camry
1990 Toyota Corolla
Indicate if
NOT in
your
possession
NOT
Estimated Market Value of YOUR Interest
on date of
marriage
on valuation date
today
$15,000.00
$14,000.00
$15,000.00
$14,000.00
$5,000.00
Jewellery, art,
electronics,
tools, sports &
hobby
equipment
Other special
items
16. TOTAL VALUE OF GENERAL HOUSEHOLD ITEMS AND
VEHICLES
$5,000.00
PART 4(c): BANK ACCOUNTS, SAVINGS, SECURITIES AND PENSIONS
Show the items owned on the dates in each of the columns below by category, for example, cash, accounts in financial institutions,
pensions, registered retirement or other savings plans, deposit receipts, any other savings, bonds, warrants, options, notes and other
securities. Give your best estimate of the market value of the securities if the items were to be sold on the open market.
•
•
•
List all your bank accounts, RRSP, RESP, investment accounts and pensions.
If you own a bank account jointly with your spouse list one-half the balance in the columns under the
appropriate dates. Also list the full balance in brackets in the “Description” column.
For estimated value of a pension put “TBD”.
•
REQUIRED: Bank statements showing the account balances on the relevant dates. For RRSP’s and
investment accounts a statement as close as possible to the relevant dates.
•
For pensions a recent pension statement from your pension plan or employer. A valuation of your
pension will be required.
Category
Institution (including location)/
Description (including issuer and date)
Savings
TD Canada Trust
Account Sole (100%)
Account
number
5555555
Amount/Estimated Market Value
on date of
on valuation date
today
marriage
$4,000.00
$5,000.00
Court File Num ber
Form 13.1: Financial Statement (Property and
Support Claims)
(Page 7)
Category
Institution (including location)/
Description (including issuer and date)
Account
number
Chequing TD Canada Trust
Account - Total as of:
Joint (50%) a) date of separation $2,000.00
b) today $1,000.00
6666666
RRSP
Standard Life
7777777
RESP
Standard Life
Investment Standard Life
Account
Pension
Amount/Estimated Market Value
on date of
on valuation date
today
marriage
$1,000.00
$500.00
$50,000.00
$55,000.00
8888888
$3,500.00
$4,000.00
9999999
$20,000.00
$10,000.00
TBD
TBD
TBD
$5,000.00
$78,500.00
$74,500.00
ABC Corporation
17. TOTAL VALUE OF ACCOUNTS, SAVINGS,
SECURITIES AND PENSIONS
$5,000.00
PART 4(d): LIFE & DISABILITY INSURANCE
List all policies in existence on the dates in each of the columns below.
List all life insurance policies you currently own and provide the following:
1)
2)
3)
4)
5)
•
•
•
Name of Insurer, Policy Type & Policy No. (if known)
Policy Owner
Beneficiary(ies)
Face Amount (Amount of Coverage)
Cash Surrender Value (if any)
If your policy is term life it will not have a cash surrender value. If your policy is whole life it will
likely have a cash surrender value which can be found on your most recent statement from your insurer.
Also list all group insurance policies and all disability/critical illness policies.
REQUIRED: A copy of your insurance policies regarding your coverage and the cash surrender
value, if any.
Company, Type &
Policy Number
Cash Surrender Value
Owner
Beneficiary Face Amount
Standard Life, Term Life,
Policy No. 4444444
Myself
Wife and
Children
$150,000.00
Standard Life, Universal
Life, Policy No. 5555555
Myself
Wife and
Children
$100,000.00
18. TOTAL CASH SURRENDER VALUE OF INSURANCE
POLICIES
on date of
marriage
$0.00
on valuation date
today
$1,500.00
$1,600.00
$1,500.00
$1,600.00
Court File Num ber
Form 13.1: Financial Statement (Property and
Support Claims)
(Page 8)
PART 4(e): BUSINESS INTERESTS
Show any interest in an unincorporated business owned on the dates in each of the columns below. An interest in an incorporated business
may be shown here or under "BANK ACCOUNTS, SAVINGS, SECURITIES, AND PENSIONS" in Part 4(c). Give your best estimate of
market value of your interest.
If you have an interest in a business it will have to be professionally valued.
Name of Firm or
Company
Interest
1234000 Ontario Inc. Sole Shareholder - 100 %
19. TOTAL VALUE OF BUSINESS INTERESTS
Estimated Market Value of YOUR Interest
on date of
on valuation date
today
marriage
TBD
TBD
TBD
$0.00
$0.00
$0.00
PART 4(f): MONEY OWED TO YOU
Give details of all money that other persons owe to you on the dates in each of the columns below, whether because of business or from
personal dealings. Include any court judgments in your favour, any estate money and any income tax refunds owed to you.
•
•
•
List any money owed to you, either from an individual or from a business. For example, if someone has
borrowed $500.00 from you and still owes you the $500.00 on the date of separation, then list it in the
middle column under valuation date.
List any income tax refunds owing to you.
List any commissions or bonuses from your employer/business and any other receivables owing to you from
corporate or unincorporated entities.
Amount Owed to You
Details
on date of
marriage
on valuation date
Loan to my Brother
today
$500.00
20. TOTAL OF MONEY OWED TO YOU
$0.00
$500.00
$0.00
PART 4(g): OTHER PROPERTY
Show other property or assets owned on the dates in each of the columns below. Include property of any kind not listed above. Give your
best estimate of market value.
•
List any other property not listed in any other asset category that you owned.
Category
Timeshare
Details
Timeshare Canada
(3 weeks annually)
Estimated Market Value of YOUR Interest
on date of
on valuation date
today
marriage
TBD
TBD
Court File Num ber
Form 13.1: Financial Statement (Property and
Support Claims)
(Page 9)
Category
Details
Estimated Market Value of YOUR Interest
on date of
on valuation date
today
marriage
$0.00
21. TOTAL VALUE OF OTHER PROPERTY
$0.00
$0.00
22. VALUE OF ALL PROPERTY OWNED ON THE VALUATION DATE (Add items [15] to [21])
$495,500.00
PART 5: DEBTS AND OTHER LIABILITIES
Show your debts and other liabilities on the dates in each of the columns below. List them by category such as mortgages, charges, liens,
notes, credit cards, and accounts payable. Don't forget to include:
• any money owed to the Canada Revenue Agency;
•
contingent liabilities such as guarantees or warranties given by you (but indicate that they are contingent); and
•
any unpaid legal or professional bills as result of this case.
•
•
•
•
List all your debts including mortgages, loans, line of credits, income and taxes payable,
outstanding legal and professional fees and credit card balances.
Include debts owing to family members or friends.
If the debt is 50/50 with your spouse list one-half the balance in the columns under the
appropriate dates and also list the full balance in brackets in the “Details” column.
For example, if your mortgage balance is $150,000.00:
1)
2)
Put $150,000.00 if the mortgage is 100% in your name
Put $75,000.00 if the mortgage is 50/50 with your spouse
•
Do not list debts which are not in your name.
•
REQUIRED: Statements/documents showing the balances of your debts on the relevant
dates.
Amount owing
Category
Details
Mortgage - Joint (50%)
Matrimonial Home - 123 Maple
Lane, Mississauga, Ontario
Total as of:
a) date of marriage $200,000.00
b) date of separation
$150,000.00
c) today $140,000.00
Line of Credit - Joint (50%)
TD Canada Trust
Total as of:
a) date of separation $20,000.00
b) today $24,000.00
Line of Credit - Sole (100%) TD Canada Trust
on date of
marriage
$100,000.00
on valuation date
today
$75,000.00
$70,000.00
$10,000.00
$12,000.00
$5,000.00
$4,000.00
Court File Num ber
Form 13.1: Financial Statement (Property and
Support Claims)
(Page 10)
Credit Card - Joint (50%)
TD Canada Trust VISA
Total as of:
a) date of separation $6,000.00
b) today $5,000.00
$3,000.00
$2,500.00
Credit Card - Sole (100%)
TD Canada Trust VISA
$2,000.00
$1,500.00
Car Loan - Sole (100%)
Toyota Financial Services re:
2008 Toyota Camry
$12,000.00
$11,000.00
Student Loan - Sole (100%)
OSAP Student Loan
$5,000.00
$112,000.00
$101,000.00
$5,000.00
Personal Loan - Sole (100%) Loan from Parents
23. TOTAL OF DEBTS AND OTHER LIABILITIES
$105,000.00
PART 6: PROPERTY, DEBTS AND OTHER LIABILITIES ON DATE OF MARRIAGE
Show by category the value of your property, debts and other liabilities, calculated as of the date of your marriage. (In this part, do not
include the value of a matrimonial home or debts or other liabilities directly related to its purchase or significant improvement, if you and
your spouse ordinarily occupied this property as your family residence at the time of separation.)
Value on Date of Marriage
Category and details
Assets
Land (Excludes Matrimonial Home value of $100,000.00)
Liabilities
$0.00
$5,000.00
$5,000.00
$0.00
$0.00
$0.00
$0.00
General household items & vehicles
Bank accounts, savings, securities, pensions
Life & disability insurance
Business interests
Money owed to you
Other property (Specify.)
Debts and other liabilities (Specify.) (Excludes Matrimonial Home debt of
$100,000.00)
$5,000.00
TOTALS
$10,000.00
$5,000.00
24. NET VALUE OF PROPERTY OWNED ON DATE OF MARRIAGE
(From the total of the “Assets” column, subtract the total of the “Liabilities” column.)
$5,000.00
25. VALUE OF ALL DEDUCTIONS (Add items [23] and [24].)
$117,000.00
Court File Num ber
Form 13.1: Financial Statement (Property and
Support Claims)
(Page 11)
PART 7: EXCLUDED PROPERTY
Show by category the value of property owned on the valuation date that is excluded from definition of "net family property" (such as
gifts or inheritances received after marriage).
Certain property received during the marriage is exempt from equalization. List any property received during
the marriage under these categories:
•
1)
2)
3)
•
gifts or inheritances from a third person
damages or settlements from personal injuries
life insurance proceeds
REQUIRED: Written document to support the amount.
Category
Value on
Valuation Date
Details
Gift
Gift received from parents during the marriage - cash
$10,000.00
Inheritance
Inheritance received from aunt during the marriage
$5,000.00
$15,000.00
26. TOTAL VALUE OF EXCLUDED PROPERTY
PART 8: DISPOSED OF PROPERTY
Show by category the value of property that you disposed of during the two years immediately preceding the making of this statement,
or during the marriage, whichever period is shorter.
•
List any property sold, disposed of, or liquidated in the past two years from the making of your financial
statement.
Category
Investment Account
Details
Value
Redeemed $10,000.00 on April 20, 2010 from Standard Life
Investment account no. 9999999
27. TOTAL VALUE OF DISPOSED OF PROPERTY
$10,000.00
$10,000.00
PART 9: CALCULATION OF NET FAMILY PROPERTY
Deductions
Value of all property owned on valuation date (from item [22] above)
Subtract value of all deductions (from item [25] above)
Subtract total value of all excluded property (from item [26] above)
$117,000.00
$15,000.00
28. NET FAMILY PROPERTY
Balance
$495,500.00
$378,500.00
$363,500.00
$363,500.00
NOTE: This financial statement must be updated no more than 30 days before any court event by either completing and filing:
!
!
a new financial statement with updated information, or
an affidavit in Form 14A setting out the details of any minor changes or confirming that the information contained in this
statement remains correct.
Court File Num ber
Form 13.1: Financial Statement (Property and
Support Claims)
(Page 12)
Sworn/Affirmed before me at
City of Mississauga
(municipality)
in
Province of Ontario
(province, state or country)
on
(date)
Commissioner for taking affidavits
(Type or print name below if signature is illegible.)
Court File Num ber
Form 13.1: Financial Statement (Property and
Support Claims)
(Page 13)
PART 2: EXPENSES
PROPOSED BUDGET
Expense
Monthly
Am ount
Repairs and maintenance
Parking
Automatic Deductions
Car Loan or Lease Payments
CPP contributions
SUBTOTAL
EI premiums
Income taxes
Health
Health insurance premiums
Employee pension contributions
Dental expenses
Medicine and drugs
Union dues
SUBTOTAL
$0.00
Housing
Rent or mortgage
Eye care
SUBTOTAL
Clothing
Property insurance
Hair care and beauty
Condominium fees
Alcohol and tobacco
Repairs and maintenance
Education (specify)
Utilities
W ater
Entertainment/recreation (including
children)
Gifts
Heat
SUBTOTAL
Electricity
Other expenses
Telephone
Life Insurance premiums
Cell phone
RRSP/RESP withdrawals
Cable
Vacations
$0.00
Internet
SUBTOTAL
$0.00
School fees and supplies
$0.00
Household Expenses
Groceries
Clothing for children
Children’s activities
Summer camp expenses
Household supplies
Debt payments
Meals outside the home
Pet care
Support paid for other children
Laundry and Dry Cleaning
Other expenses not shown above
(specify)
SUBTOTAL
$0.00
Personal
Property taxes
SUBTOTAL
$0.00
$0.00
Childcare Costs
Daycare expense
SUBTOTAL
$0.00
Babysitting costs
SUBTOTAL
Transportation
Public transit, taxis
Gas and oil
Car insurance and license
$0.00
Total Amount of Monthly Expenses
Total Amount of Yearly Expenses
$0.00
$0.00
Court File Num ber
Form 13.1: Financial Statement (Property and
Support Claims)
(Page 14)
FINANCIAL STATEMENT
SUMMARY PAGE
BUDGET
Income
Income From All Sources
Monthly
Other Benefits
Total Monthly Income and Benefits
$7,993.87
$0.00
$7,993.87
0
Expenses
Automatic Deductions
Actual
Proposed
Total Expenses
$2,267.53
$1,863.00
$415.00
$760.00
$90.00
$994.00
$120.00
$245.00
$1,170.00
$7,924.53
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Monthly Surplus / (Deficit)
$69.34
$7,993.87
Housing
Utilities
Household
Childcare Costs
Transportation
Health
Personal
Other
NET FAMILY PROPERTY
Assets
Land
Valuation Date
[15]
General Household Items and Vehicles
[16]
Bank Accounts, Savings, Securities and Pensions
[17]
Life and Disability Insurance
[18]
Business Interests
[19]
Money Owed to You
[20]
Other Property
[21]
Total Assets [22]
$400,000.00
$15,000.00
$78,500.00
$1,500.00
$0.00
$500.00
$0.00
$495,500.00
Deductions
Debts and Other Liabilities on Valuation Date
[23]
Net Value of Property Owned on Date of Marriage
[24]
Total Deductions [25]
$112,000.00
$5,000.00
$117,000.00
[26]
$15,000.00
Net Fam ily Property
$363,500.00
Exclusions
Excluded Property owned on Valuation Date
([Assets] minus [Deductions] minus [Exclusions])
Notes:
Schedule A
Additional Sources of Income
Line
1.
Income Source
Net partnership income
Annual Amount
2.
Net rental income (Gross annual rental income of
3.
Total amount of dividends received from taxable Canadian corporations
4.
Total capital gains (
5.
Registered retirement savings plan withdrawals
6.
Any other income (specify source)
)
) less capital losses (
)
Subtotal
$0.00
Schedule B
Special or Extraordinary Expenses for the Child(ren)
Child’s Nam e
Expense
Amount/yr.
Available Tax
Credits or
Deductions*
Total Net Annual Amount
Total Net Monthly Amount
$0.00
$0.00
* Some of these expenses can be claimed in a parent’s income tax return in relation to a tax credit or deduction
(for exam ple childcare costs). These credits or deductions m ust be shown in the above chart.
I attach proof of the above expenses.
I earn
per year which should be used to determine my share of the above expenses.
NOTE:
Pursuant to the Child Support Guidelines, a court can order that the parents of a child share the costs of the following
expenses for the child:
!
Necessary childcare expenses;
!
Medical insurance premiums and certain health-related expenses for the child that cost more than $100 annually;
!
Extraordinary expenses for the child’s education;
!
Post-secondary school expenses; and,
!
Extraordinary expenses for extracurricular activities.