Claim For Special/extraordinary Expenses Form

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SCHEDULE “A”
(04/07)
IN THE PROVINCIAL COURT OF NEWFOUNDLAND AND LABRADOR
COURT CENTRE: __________________________
Court File No. ____________________
Claim for Special/Extraordinary Expenses
Name: __________________________ (Applicant/Respondent)
Date: ___________________________
Under section 7 of the Child Support Guidelines Regulations, NLR 40/98, I am claiming an
additional amount to assist with the following expenses:
(Check all appropriate items and attach
supporting documentation where available.)
□
1.
Child care expenses incurred as a result of the custodial parent’s employment,
illness, disability or education or training for employment.
Monthly: _________________
Yearly: _________________
□
2.
The portion of medical and dental insurance premiums attributable to the child.
Monthly: _________________
Yearly: _________________
□
3.
Health related expenses that exceed insurance reimbursement by at least
$100.00 annually per illness or event, including orthodontic treatment;
professional counselling provided by a psychologist, social worker, psychiatrist or
other person; physiotherapy; occupational therapy; speech therapy; prescription
drugs; hearing aids; orthotic and other similar devices, and, glasses and contact
lenses, please specify: ____________________________________________
Monthly: _________________
Yearly: _________________
□
4.
Extraordinary expenses for primary or secondary school education or for
educational programs that meet the child’s particular needs.
Monthly: _________________
Yearly: _________________
□
5.
Expenses for post secondary education.
Monthly: _________________
Yearly: _________________
□
6.
Extraordinary expenses for extracurricular activities.
Monthly: _________________
Yearly: _________________
I am claiming $_______________, taking into account subsidies, benefits or income tax
deductions or credits relating to the expense.

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