"Support Enforcement Program (Sep) Statement of Finances" - Newfoundland and Labrador, Canada

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Court Location
SUPPORT
ENFORCEMENT
Court File No.
PROGRAM (SEP)
Unified Family Court
Provincial
Supreme
SEP Account No.
STATEMENT OF FINANCES
-FOR OFFICE USE ONLY-
Please Print. Do not fill in shaded areas.
A. Debtor Information
Last Name
First Name
Middle Name
Home Phone
Cell Phone
Street No.
Street Name
Apt. Name and No.
P.O. Box or Rural Route No.
City/Town
Prov./Terr
Postal Code
Email Address
Date of Birth
Social Insurance No.
Driver's Licence No./Province
MCP No.
DD
MM
YYYY
Mother’s Maiden Name
Present Marital Status
Name of Present Spouse
Single
Married
Other
Address of Present Spouse
(If different from yours)
B. Present Dependents
“ “
Do you have any children living with you who are
If yes, provide the following information in the spaces below:
legally dependent on you for financial support?
No
Yes
Full name of Dependent
Age
Relationship to you
“ “
Do you have any other dependents who are
If yes, provide the following information in the spaces below:
dependent on you for financial support?
No
Yes
Full name
Age
Relationship to you
Address
Reason for dependency
Full name
Age
Relationship to you
Address
Reason for dependency
C. Employment
(Please indicate your current and previous 2 employers)
Name of Current Employer
Telephone No.
Mailing Address
Postal Code
C. cont.
Page 1 of 8
Court Location
SUPPORT
ENFORCEMENT
Court File No.
PROGRAM (SEP)
Unified Family Court
Provincial
Supreme
SEP Account No.
STATEMENT OF FINANCES
-FOR OFFICE USE ONLY-
Please Print. Do not fill in shaded areas.
A. Debtor Information
Last Name
First Name
Middle Name
Home Phone
Cell Phone
Street No.
Street Name
Apt. Name and No.
P.O. Box or Rural Route No.
City/Town
Prov./Terr
Postal Code
Email Address
Date of Birth
Social Insurance No.
Driver's Licence No./Province
MCP No.
DD
MM
YYYY
Mother’s Maiden Name
Present Marital Status
Name of Present Spouse
Single
Married
Other
Address of Present Spouse
(If different from yours)
B. Present Dependents
“ “
Do you have any children living with you who are
If yes, provide the following information in the spaces below:
legally dependent on you for financial support?
No
Yes
Full name of Dependent
Age
Relationship to you
“ “
Do you have any other dependents who are
If yes, provide the following information in the spaces below:
dependent on you for financial support?
No
Yes
Full name
Age
Relationship to you
Address
Reason for dependency
Full name
Age
Relationship to you
Address
Reason for dependency
C. Employment
(Please indicate your current and previous 2 employers)
Name of Current Employer
Telephone No.
Mailing Address
Postal Code
C. cont.
Page 1 of 8
C. Employment cont.
Nature of Business
Position Held
From DD/MM/YY
To DD/MM/YY
Place of Employment
Gross monthly wages or salary
Net monthly wages or salary
Same as Above
Copy of pay stub attached
Other (specify)
Previous Employer
Telephone No.
Mailing Address
Postal Code
Nature of Business
Position Held
From DD/MM/YY
To DD/MM/YY
Place of Employment
Gross monthly wages or salary
Net monthly wages or salary
Same as Above
Copy of pay stub attached
Other (specify)
Are you qualified as a tradesperson, professional or otherwise?
If yes, state nature of all qualifications or special training:
No
Yes
Do you receive bonuses from your employer?
If yes, explain:
No
Yes
Do you receive any money from any commission work?
If yes, state type of work, amount of income received,
No
Yes
and the most recent commission received:
Do you receive money from other part time employment?
If yes, list employer's name(s) and amount of income:
No
Yes
Do you have any income producing hobbies?
If yes, state type of hobby and amount of income received per year:
No
Yes
Are you the sole income earner in your household?
If no, state who the other income earner is:
No
Yes
Please list all other income:
Dividends
$_______________
EI
$________________
Rental Income$_______________
CPP
$________________
Annuities
$_______________
Other
$________________
Total
Income: $_______________________________
Pensions
$_______________
Page 2 of 8
D. Income from self employment
Type of business
Name of business
Telephone No.
Business Address:
Postal Code
Is this business a:
What is the percentage of the
What is the net book value
What is the estimated market
Business owned by you?
of the Business?
value of the Business?
proprietorship
joint venture
partnership
corporation
______________________%
List the names, addresses and telephone numbers of any partners, principals or participants in your business:
Name
Address
Telephone No.
If the Business is a Corporation complete the following:
Registered name of Corporation
Head Office Address
Place of Incorporation
Are you an
No
Officer or
Director?
Yes....Title ______________________________________________________________________________________
Total number of shares issued and outstanding:
Total number of shares of each class held by you:
(describe type and class of shares)
Class
Number
Net Book Value
Class
Number
Net Book Value
Total amount of all loans payable to you by the Corporation
Terms of repayment
Amount
$__________________
________________________________________________________________
Interest earned (if any)
$__________________
Itemize your yearly income from self-employment below:
Itemize other benefits (company car, house, loans, savings
Salary
$_____________
plans, share purchase options, etc) Describe:
Bonuses
$_____________
____________________________________
$__________________
Dividends
$_____________
____________________________________
$__________________
Other (automobile allowances,
____________________________________
$__________________
expenses etc.) describe
_________________________
$_____________
____________________________________
$__________________
_________________________
$_____________
____________________________________
$__________________
_________________________
$_____________
____________________________________
$__________________
TOTAL
INCOME
$_____________
ATTACH A COPY OF MOST RECENT FINANCIAL STATEMENT
Page 3 of 8
E. Monthly Cash Flow Statement
Your Total Monthly Income (Sections C + D) ................................................................................................................................
$ _______________ (A)
Your Monthly Expenses: (only include your portion of expenses if there is another income in the household):
1. Rent or Mortgage Payments (name landlord or mortgagee) ....................................................................................
$ _______________
2. Property Tax ............................................................................................................................................................
$ _______________
3. Utilities ......................................................................................................................................................................
$ _______________
4. Groceries (food, toiletries etc.) .................................................................................................................................
$ _______________
5. Clothing ...................................................................................................................................................................
$ _______________
6. Transportation (fuel, parking, repairs, public transit etc.) .........................................................................................
$ _______________
7. Personal Expenses (prescription drugs, medical and dental expenses
expenses not covered by insurances etc.)...............................................................................
$ _______________
8. Home Insurance ......................................................................................................................................................
$ _______________
9. Vehicle Insurance ....................................................................................................................................................
$ _______________
10. Life Insurance ..........................................................................................................................................................
$ _______________
11. Disability Insurance...................................................................................................................................................
$ _______________
12. Other (Specify i.e. child support) ..............................................................................................................................
$ _______________
Sub-total Items 1-12
$ _______________ (B)
List your monthly payments (loans, credit cards, personal debts etc, below)
Type of Debt
To Whom Payable
Amount Outstanding
Monthly Payment
_________________
___________________________________
$_______________________________________
$ ________________
_________________
___________________________________
$_______________________________________
$ ________________
_________________
___________________________________
$_______________________________________
$ ________________
_________________
___________________________________
$_______________________________________
$ ________________
Sub-total debt payments
$ ________________(C)
Total expenses & payments (B + C)
$ ________________(D)
Net Monthly Income (A - D)
$_________________
_________________
F. Personal Liabilities
List other personal liabilities (personal guarantees, encumbrances and debts specifically attached to personal property etc.)
List creditor and amount
Name of creditor
Address of Creditor
Amount
Total Personal Liabilities: _____________________________________
Page 4 of 8
G. Assets
Real Estate:
Fill in all the requested information below regarding all Real Estate (names, rental properties, cottages, condominiums, etc.)
inside and outside the province of Newfoundland and Labrador in which you own an interest.
Address
Legal Description
Purchase Price
Balance Owing
Current Market Value
1.
2.
3.
List the Name and Address of the Mortgagee for each property described above
1.
2.
3.
Motor vehicle etc.
Fill in the requested information regarding all motor vehicles (cars, trucks, vans, farm machinery, construction equipment,
recreation vehicles, aircraft, boats, etc.) in which you own an interest.
Purchase
Balance
Current
Type - Make - Model - Year
Serial No.
Price
Owing
Market Value
Equity
1.
2.
3.
List the name and address of the creditor to whom the balance is owed for the vehicles described on previous page.
1.
2.
3.
Bank Accounts etc.:
List all chequing and savings accounts, term deposits, registered savings plans, annuities, etc.:
Type of Deposit
Name of Institution
Account No.
Branch Address
Amount
If you have holdings in a Public Corporation(s) complete the following:
List your shares, options, warrants, bonds and debentures held and their current market value below.
Type
Number
Issuer
Current Market Value
G. cont.
Page 5 of 8
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