Name of Court) Form 13: Financial Statement (Support Claims) sworn/affirmed




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ONTARIO









Court File Number

     


(Name of Court)

Form 13: Financial Statement (Support Claims) sworn/affirmed

at

     




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.

YOU DO NOT NEED TO COMPLETE THIS FORM IF:




·

your only claim for support is for child support in the table amount specified under the Child Support Guidelines and you are not making or responding to a claim described in paragraph 3 below.

2.

USE THIS FORM IF:




·

you are making or responding to a claim for spousal support; or




·

you are responding to a claim for child support; or




·

you are making a claim for child support in an amount different from the table amount specified under the Child Support Guidelines.




You must complete all parts of the form UNLESS you are ONLY responding to a claim for child support in the table amount specified under the Child Support Guidelines AND you agree with the claim. In that case only complete Parts 1, 2 and 3.

3.

DO NOT USE THIS FORM AND INSTEAD USE FORM 13.1 IF:




·

you are making or responding to a claim for property or exclusive possession of the matrimonial home and its contents; or




·

you are making or responding to a claim for property or exclusive possession of the matrimonial home and its contents together with other claims for relief.

1.

My name is (full legal name)

     




I live in (municipality & province)

     




and I swear/affirm that the following is true:




My financial statement set out on the following (specify number)

     

pages is accurate to the




best of my knowledge and belief and sets out the financial situation as of (give date for which information is accurate)




     

for




Check one or more boxes, as circumstances require.



me



the following person(s): (Give name(s) and relationship to you.)

     

Form 13: 

Financial Statement (Support Claims)

(page 2)

Court file number

Error: Reference source not found












NOTE: When you show monthly income and expenses, give the current actual amount if you know it or can find out. To get a monthly figure you must multiply any weekly income by 4.33 or divide any yearly income by 12.

PART 1: INCOME

for the 12 months from (date)

     

to (date)

     

Include all income and other money that you get from all sources, whether taxable or not. Show the gross amount here and show your deductions in Part 3.

CATEGORY

Monthly




CATEGORY

Monthly

1.

Pay, wages, salary, including overtime (before deductions)

     

9.

Rent, board received

     




10.

Canada Child Tax Benefit

     

2.

Bonuses, fees, commissions

     

11.

Support payments actually received

     

3.

Social assistance

     

12.

Income received by children

     

4.

Employment insurance

     

13.

G.S.T. refund

     

5.

Workers’ compensation

     

14.

Payments from trust funds

     

6.

Pensions

     

15.

Gifts received

     

7.

Dividends

     

16.

Other (Specify. If necessary, attach an extra sheet.)

     

8.

Interest

     













17.

INCOME FROM ALL SOURCES

     




PART 2: OTHER BENEFITS

Show your non cash benefits — such as the use of a company car, a club membership or room and board that your employer or someone else provides for you or benefits that are charged through or written off by your business.

ITEM

DETAILS

Monthly Market Value

     

     

     

18. TOTAL

     

19.

GROSS MONTHLY INCOME AND BENEFITS (Add [17] plus [18].)

$

     







PART 3: AUTOMATIC DEDUCTIONS FROM INCOME

for the 12 months from (date)

     

to (date)

     




TYPE OF EXPENSE

Monthly




TYPE OF EXPENSE

Monthly

20.

Income tax deducted from pay

     

25.

Group insurance

     

21.

Canada Pension Plan

     

26.

Other (Specify. If necessary, attach an extra sheet.)

     

22.

Other pension plans

     

23.

Employment insurance

     

24.

Union or association dues

     

27.

TOTAL AUTOMATIC DEDUCTIONS

     

28.

NET MONTHLY INCOME (Do the subtraction: [19] minus [27].)

$

     




Form 13: 

Financial Statement (Support Claims)

(page 3)

Court file number

Error: Reference source not found












PART 4: TOTAL EXPENSES

for the 12 months from (date)

     

to (date)

     

NOTE: If you need to complete this Part (see instructions on page 1), you must set out your TOTAL living expenses, including those expenses involving any children now living in your home. This part may also be used for a proposed budget. To prepare a proposed budget, photocopy Part 4, complete as necessary, change the title to “Proposed Budget” and attach it to this form.




TYPE OF EXPENSE

Monthly







TYPE OF EXPENSE

Monthly

Housing




Child(ren)

29.

Rent/mortgage

     




57.

School activities (field trips, etc.)

     

30.

Property taxes & municipal levies

     




58.

School lunches

     

31.

Condominium fees & common expenses

     




59.

School fees, books, tuition, etc. (for children)

     

32.

Water

     




60.

Summer camp

     

33.

Electricity & heating fuel

     




61.

Activities (music lessons, clubs, sports)

     

34.

Telephone

     




62.

Allowances

     

35.

Cable television & pay television

     




63.

Baby sitting

     

36.

Home insurance

     




64.

Day care

     

37.

Home repairs, maintenance,

gardening



     




65.

Regular dental care

     




66.

Orthodontics or special dental care

     

Sub-total of items [29] to [37]

     




67.

Medicine & drugs

     

Food, Clothing and Transportation etc.




68.

Eye glasses or contact lenses

     

38.

Groceries

     




Sub-total of items [57] to [68]

     

39.

Meals outside home

     




Miscellaneous and Other

40.

General household supplies

     




69.

Books for home use, newspapers, magazines, videos, compact discs

     

41.

Hairdresser, barber & toiletries

     




42.

Laundry & dry cleaning

     




70.

Gifts

     

43.

Clothing

     




71.

Charities

     

44.

Public transit

     




72.

Alcohol & tobacco

     

45.

Taxis

     




73.

Pet expenses

     

46.

Car insurance

     




74.

School fees, books, tuition, etc.

     

47.

Licence

     




75.

Entertainment & recreation

     

48.

Car loan payments

     




76.

Vacation

     

49.

Car maintenance and repairs

     




77.

Credit cards (but not for expenses mentioned elsewhere in the statement)

     

50.

Gasoline & oil

     




51.

Parking

     




78.

R.R.S.P. or other savings plans

     

Sub-total of items [38] to [51]

     




79.

Support actually being paid in any other case

     

Health and Medical (do not include child(ren)’s
expenses)








80.

Income tax and Canada Pension Plan (not deducted from pay)

     

52.

Regular dental care

     




53.

Orthodontics or special dental care

     




81.

Other (Specify. If necessary attach an extra sheet.)

     

54.

Medicine & drugs

     




55.

Eye glasses or contact lenses

     




Sub-total of items [69] to [81]

     

56.

Life or term insurance premiums

     




82.

Total of items [29] to [81]

     

Sub-total of items [52] to [56]

     

SUMMARY OF INCOME AND EXPENSES

Net monthly income (item [28] above)

=$

     




Subtract actual monthly expenses (item [82] above)

=$

     




ACTUAL MONTHLY SURPLUS/DEFICIT

=$

     




Form 13: 

Financial Statement (Support Claims)

(page 4)

Court file number

Error: Reference source not found












PART 5: OTHER INCOME INFORMATION

1.

I am



employed by (name and address of employer)







     






self-employed, carrying on business under the name of (name and address of business)







     






unemployed since (date when last employed)







     

2.

I attach the following required information (if you are filing this statement to update or correct an earlier statement, then you do not need to attach income tax returns that have already been filed with the court.):






a copy of my income tax returns that were filed with the Canada Revenue Agency for the past 3 taxation years, together with a copy of all material filed with the returns and a copy of any notices of assessment or re-assessment that I have received from the Canada Revenue Agency for those years; or






a statement from the Canada Revenue Agency that I have not filed any income tax returns from the past 3 years; or






a direction in Form 13A signed by me to the Taxation Branch of the Canada Revenue Agency for the disclosure of my tax returns and notices of assessment to the other party for the past 3 years.




I attach proof of my current income, including my most recent






pay cheque stub.



employment insurance stub.



worker’s compensation stub.






pension stub.



other. (Specify.)

     

3.



(check if applicable) I am an Indian within the meaning of the Indian Act (Canada) and all my income is tax exempt and I am not required to file an income tax return. I have therefore not attached an income tax return for the past three years.

PART 6: 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. Indicate at paragraph 1 or 2, whether you are living with another person (for example, spouse, roommate or tenant). If you complete paragraph 2, also complete paragraphs 3 to 6.

1.



I live alone.

2.

I am living with (full legal name of person)

     

3.

This person has (give number)

     

child(ren) living in the home.

4.

This person



works at (place of work or business)

     






does not work outside the home.




5.

This person



earns (give amount) $

     

per

     






does not earn anything.




6.

This person



contributes about $

     

per

     

towards the household expenses.






contributes no money to the household expenses.

Form 13: 

Financial Statement (Support Claims)

(page 5)

Court file number

Error: Reference source not found












PART 7: PROPERTY

LAND

Kind of Property

Address of Property

Type of Ownership (Give your percentage of interest)

Estimated Market Value of Your Interest

     

     

     

     

83. TOTAL VALUE

     

GENERAL ITEMS AND VEHICLES (including household goods and furniture, jewellery, cars, boats, tools, sports and hobby equipment)

Description (including where located, year and make)

Estimated Market Value (not replacement cost)

     

     

84. TOTAL VALUE

     

BANK ACCOUNTS, SAVINGS, SECURITIES AND PENSIONS (including R.R.S.P.’s other savings plans, cash, accounts in financial institutions, stocks, bonds, term deposits and controlling interest in an incorporated business)

Item/Type

Institution (include location)/
Description (including issuer and date)

Account Number

Date of Maturity

Amount/Estimated Market Value

     

     

     

     

     

85. TOTAL VALUE

     

LIFE AND DISABILITY INSURANCE (List all policies now in existence.)

Company, Type & Policy No.

Beneficiary

Face Amount

Today’s Cash Surrender Value

     

     

     

     

86. TOTAL VALUE

     

BUSINESS INTERESTS (Show any interest in an unincorporated business owned today.)

Name of Firm or Company

Nature and Location of Business

Interest

Estimated Market Value of Your Interest

     

     

     

     

87. TOTAL VALUE

     

MONEY OWED TO YOU (including any court judgments in your favour, any estate money and any income tax refunds owed to you.)

Details (including name of debtors)

Amount Owed to You

     

     

88. TOTAL OF MONEY OWED TO YOU

     

OTHER PROPERTY

Type of Property

Description and Location

Estimated Market Value

     

     

     

89. TOTAL VALUE OF OTHER PROPERTY

     







90. TOTAL VALUE OF ALL PROPRETY (Add items [83] to [89].)

     

Form 13: 

Financial Statement (Support Claims)

(page 6)

Court file number

Error: Reference source not found












PART 8: DEBTS AND OTHER LIABILITIES

Debts and other liabilities may include any money owed to the Canada Revenue Agency, contingent liabilities such as guarantees or warranties given by you (but indicated that they are contingent), any unpaid legal or professional bills as a result of this case, mortgages, charges, liens, notes, credit cards and accounts payable.

Type of Debt

Creditor

Details

Monthly Payments

Full Amount Now Owing

Bank, trust or finance company, or credit union loans

     

     

     

     

Amounts owed to credit card companies

     

     

     

     

Other debts

     

     

     

     

91. TOTAL OF DEBTS AND OTHER LIABILITIES:

     




PART 9: SUMMARY OF ASSETS AND LIABILITIES




Amounts

TOTAL ASSETS (from item [90] above)

$

     

Subtract TOTAL DEBTS (from item [91] above)

$

     

92. NET WORTH

$

     



I do not expect changes in my financial situation.



I do expect changes in my financial situation as follows:




     



I attach a proposed budget in the format of Part 4 of this form.

NOTE: As soon as you find out that the information in this financial statement is incorrect or incomplete, or there is a material change in your circumstances that affects or will affect the information in this financial statement, you MUST serve on every other party to this case and file with the court:

·

a new financial statement with updated information, or

·

if changes are minor, an affidavit in Form 14A setting out the details of these changes.

Sworn/Affirmed before me at

     










municipality







in

     













province, state or country







Signature

on

     













(This form is to be signed in front of a lawyer, justice of the peace, notary public or commissioner for taking affidavits.)




date




Commissioner for taking affidavits







(Type or print name below if signature is illegible.)




FLR 13 (September 1, 2005)

Page of





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