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SUPREMEi COURT OF QUEENSLAND

Registry:

Number:


Applicant: (Insert name)

AND


[First] Respondent (Insert name)

AND


[Second respondent] (Insert Name)

STATEMENT OF FINANCIAL POSITION

Enforcement creditor: (Name)

Enforcement debtor: (Name)

Instructions for enforcement debtor completing statement:

  • You must complete this statement and return it to the enforcement creditor at (insert address) within 14 days after you received it.

  • If you fail to return the completed statement you may be liable to punishment for contempt of court.

  • All questions must be answered.

  • Use the word ‘Nil’ if appropriate.

  • If you would like to complete this form electronically, a copy can be found on the Queensland Courts website at http://www.courts.qld.gov.au/107.htm#ucpr (then open Form 71). You will need to print your completed form to sign it and send it to the enforcement creditor. Where Yes No appears, double click then select ‘Not checked’ or ‘Checked’ as appropriate.

  • If you are completing this form manually, where Yes No appears, tick or cross the appropriate box.

  • Estimates can only be given if, after reasonable enquiry, you are unable to give an accurate answer. Any estimates should have the letter ‘E’ inserted before the amount shown.

  • If you are completing this form manually and you need more room to answer any of the questions, attach a separate page with your answers.


PART 1–INCOME


1.1

Are you currently employed? Yes No

If ‘no’, please go to Item 1.10



1.2

What is your employer’s name:




1.3

What is your employer’s address:




1.4

What is your occupation or position:




1.5

When did your current employment commence?




1.6

What is the amount of all payments actually received by you from this employment (after deduction of tax) currently per week?

(If the amount varies from week to week, state a typical amount.)






1.7

What are the dates of receipt of the last four payments in Item 1.6?




1.8

Are these Item 1.6 payments made directly into an account with a bank or financial institution?

Yes No

If ‘yes’, for each employment payment state:


  • the name of the bank or financial institution




  • the name of the account




  • the BSB number




  • the account number




1.9

If any regular deductions are made from the payments detailed in Item 1.6, other than for tax, what is the purpose and weekly amount of each deduction?




1.10

On what date did your last period of employment end?




1.11

What was the length of your last period of employment?




1.12

What is the name of your last employer




1.13

What is the address of your last employer




1.14

What was the value of your average weekly earnings (after deduction of tax) during your last period of employment?




1.15

Are you in receipt of any pension, benefits, annuities or other similar payment from any government department, former employer, superannuation fund or other body? Yes No

If ‘no’, please go to Item 1.17.

If ‘yes’, in respect of each source of such payment/s state:


  • the source of the payment (e.g. CentreLink)




  • the nature of the payment (e.g. disability pension)




  • the value per week of the amount actually received




  • the amount (if any) deducted for tax




1.16

Are these Item 1.15 payments made directly into an account with a bank or financial institution? Yes No

If so, for each payment state:



  • the name of the bank or financial institution?







  • the BSB number




  • the account number




1.17

Are you self-employed? Yes No

If ‘yes’, state:



  • your occupation




  • the total amount received by you as a self-employed person during the last financial year




  • the total amount of expenditure incurred by you in earning income during that financial year




1.18

In the last 12 months, did you receive any income from any of the following sources, and if so, what was the total amount of each received in the last 12 months or the last financial year (specifying the relevant period):

  • dividends




  • interest from banks, building societies, credit unions, other financial institutions, shares, etc.




  • sale of shares




  • money from trusts or estates







  • rent payments




  • board payments




  • worker’s compensation payments




  • maintenance payments (child or spouse)




  • any other income from any source (give details)




1.19

Are you wholly or partly dependent on any other person for financial support? Yes No

If ‘yes’, what is the:



  • name of that person?




  • relationship of that person to you?




  • average weekly value of that support?




1.20

Is any other person wholly or partly dependent on you for financial support? Yes No

If ‘yes’, what is the:



  • name of that person?




  • relationship of that person to you?




  • average weekly value of that support?




1.21

Are you expecting to receive a lump sum payment in the foreseeable future? Yes No

If ‘yes’, what is the:



  • source of the payment?




  • amount of the payment?




  • expected date of receipt?




1.22

Provide copies of your notices of assessment (from the Australian Taxation Office) for the last 2 years ending 30 June.


PART 2–EXPENSES


2.1

Do you incur any expenses in obtaining any of the income disclosed above, other than expenditure in earning income from self-employment? Yes No

If ‘Yes’ what are the:



  • details of expenses incurred?




  • average annual or weekly value of each expense?




2.2

Do you (not your employer on your behalf) make contributions to any superannuation fund/s? Yes No

If yes, what is the:



  • name of each such fund?




  • total contribution by you in the last 12 months to each such fund?




2.3

What are your average weekly personal expenses for the categories listed below?

  • food and household supplies




  • accommodation expenses (including rent, board, hospital, nursing home etc. but excluding mortgage payments) and state to whom these expenses are paid







  • home maintenance and repairs




  • lay-by payments




  • electricity, gas, telephone (including mobile telephones) and internet expenses




  • mortgage payments




  • child care




  • child maintenance actually paid




  • medical, dental, optical, ambulance and pharmacy







  • school fees and other educational expenses




  • insurance policy premiums - specify types of insurance as well as amounts




  • public transport fares




  • vehicle expenses (including registration, insurance, maintenance and running expenses)




  • entertainment and other recreational expenses




  • union or association fees







2.4

Do you have any goods or assets (not real property) subject to a lease or hire purchase agreement? Yes No

If yes, provide a copy of each lease or hire purchase agreement.

If yes, for each lease or hire purchase agreement state:





  • the subject goods or assets







  • the name of the hire purchase company or lessor







  • when and in what amounts periodic payments are required to be made







  • the balance owing under the hire purchase agreement







  • how much has been paid under the lease or hire purchase agreement to date







  • The commencement date and term of the lease











PART 3–ASSETS


3.1

Do you own or have any other interest in any land (including any house, home unit, farm, or tenancy of any property) either alone or with another or others? Yes No

If ‘yes’, for each piece of land:



  • what is the location and real property description of the land?




  • what interest do you have in it (e.g. owner, tenant)?




  • do you hold that interest alone?




  • if not, who else has an interest in the land, and what is the extent of their interests?




  • what is the value of your interest in the land?




3.2

Do you have any money in bank accounts, building societies, credit unions or similar financial institutions? Yes No

If ‘yes’, for each account:



  • what is the name of the institution?




  • what name is the account in?




  • what is the account number?




  • what is the current amount in the account?




3.3

Do you have any life insurance policies? Yes No

If ‘yes’, for each policy:



  • what is the name of the insurer?




  • what is the policy number?




  • what is the surrender value?




3.4

Do you own any shares or debentures? Yes No

If ‘yes’, for each holding state:



  • the name of the corporation which has issued the shares or debentures







  • the current market value of the shares or debentures




3.5

Do you hold an interest in any business, partnership, etc.? Yes No

If ‘yes’, for each state:



  • the name of the business/partnership




  • the current market value of the business/partnership







  • the name of the holder of any other interest

and the extent of that interest




3.6

Do you have an interest in any deceased estate or trust? Yes No

If ‘yes’, for each identify:



  • the name of the estate or trust




  • the nature and extent of the interest




  • the value of the interest




3.7

Do you have an interest in any superannuation fund? Yes No

If yes, state:









  • the nature and present value of the interest




  • the date and amount of expected distributions from the fund, and

provide a statement from the Trustee of the fund as to the value of the interest




3.8

Is there any money owing to you from any source? Yes No

If ‘yes’, for each debt owed state:



  • whether the money is owing under an agreement in writing. If so, provide a copy of the agreement.




  • who owes you the money




  • the amount owed




  • when the debt is likely to be repaid




3.9

Do you have any money on hand? Yes No

If ‘yes’:



  • what is the amount?




  • where is the money held?




3.10

Do you own any vehicles?

Yes No


If ‘yes’, for each vehicle state the make, model, year, registration number and current market value.




3.11

Do you own any caravans, boats, trailers, jet skis or other similar items?

Yes No


If ‘yes’, for each item state the make, model, year, registration number and current market value.




3.12

Do you own any furniture and/or other household goods (e.g. whitegoods, appliances)?

Yes No


  • Identify significant items

  • What is the estimated value of these items?




3.13

Do you own any jewellery and/or other personal effects?

Yes No


  • Identify significant items

  • What is the estimated value of these items?




3.14

Do you own or have any interest in any property of any kind, including intellectual property (e.g. business or product names, trademarks, computer software, domain names), goodwill, stock in trade, livestock, artwork other than as set out above?

Yes No


If ‘yes’, identify each item of property and give its estimated value.





PART 4–LIABILITIES


4.1

Have you mortgaged or charged any property? Yes No

If ‘yes’, provide a copy of the mortgage or charge and for each mortgage or charge state:



  • if registered, its registered number and date of registration

  • name of mortgagee or chargee




  • details of the encumbered property







  • the frequency (e.g. weekly, monthly) and amount of the payments




4.2

Do you have any bank loans or overdrafts? Yes No

If ‘yes’, for each loan/overdraft, state:



  • the name of the bank or financial institution




  • total amount owing and limit of the overdraft




  • the frequency (e.g. weekly, monthly) and the average amount of the payments







  • if the loan or overdraft is secured against any asset – give details.

  • any minimum requirements for repayment



4.3

Do you have any credit cards? Yes No

    If ‘yes’, for each card state:




  • name of the financial institution which issued the card






  • the debit balance of the card



4.4

Do you owe anyone any money other than as disclosed above (including tax liabilities)?

Yes No


If ‘yes’, state:




  • the amount owing




  • the frequency and amount of any regular repayments




  • when the debt is payable







  • provide a copy of any relevant agreements

4.5

    Have you guaranteed the debts of any other person or corporation? Yes No

If yes, state:




  • the names of the principal debtor and the creditor







  • whether the guarantee was wholly or partly in writing and, if so, provide a copy of the written instrument and state the monetary limit of the guarantee





PART 5–PROPOSAL FOR PAYMENT


5.1

Do you have any proposal for the payment or satisfaction of the debt to the enforcement creditor? Yes No

If ‘yes’, what do you propose?



VERIFICATION OF STATEMENT


(Full name of deponent) of (residential or business address or place of employment), (occupation or other description) states on oath [or: solemnly and sincerely affirms and declares]:

  • The information set out in this statement is true, and correct to the best of my knowledge and belief. Where I have given an estimate in this statement, it is given in good faith to the best of my knowledge and belief.

  • To the best of my knowledge and belief I have no income, property or financial resources other than as set out in this statement.

Sworn [or: affirmed] by (full name) on (date) at (place) in the presence of:

(Signature of deponent)

…………………………………………….




(Signature of person taking statement)

………………………………………………..




(Full name of Deponent/Enforcement debtor)

…………………………………………….



(Full name of Witness)

……………………………………………….



Deponent

Insert qualifications of Witness

Lawyer / J.P. / Comm. Dec / Notary Public /etc.




(Certificate of reading or signature where required under Rule 433 UCPR) :


  • The Witness, by signing, certifies that this statement of the enforcement debtor's financial position was read in the presence of the deponent who both seemed to understand it and signified that he or she made the statement but was incapable of reading it. (See R433(1) UCPR)




  • The Witness, by signing, certifies that this statement of the enforcement debtor's financial position was read in the presence of the deponent who both seemed to understand it and signified that he or she had made the affidavit but was physically incapable of signing it. (See Rule 433(2) UCPR)



i. For an application in the District Court or a Magistrates Court, substitute “District Court” or “Magistrates Courts” respectively.

STATEMENT OF FINANCIAL POSITION Name:

Form 71 Version 3 Address:

Uniform Civil Procedure Rules 1999 Phone No:

Rule 807 Fax No:





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