Form 65 - Monthly Income And Expense Statement Of The Bankrupt And The Family Unit And Information (Or Amended Information) Concerning The Financial Situation Of The Individual Bankrupt
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1
2FORM 65
Monthly Income and Expense Statement of the Bankrupt and the Family Unit
and Information (or Amended Information) Concerning
the Financial Situation of the Individual Bankrupt
(Section 68 and Subsection 102(3) of the Act and Rule 105(4))
(Title Form 1)
The information concerning the monthly income and expense statement of the bankrupt and the family unit, the financial situation of the bankrupt
and the bankrupt’s obligation to make payments required under section 68 of the Act to the estate of the bankrupt are as follows:
MONTHLY INCOME
Bankrupt
Other members of the
Total
family unit
Net employment income . . . . . . . . . . . . . . . . . . . . ____________
Net pension/Annuities . . . . . . . . . . . . . . . . . . . . . . ____________
Net child support . . . . . . . . . . . . . . . . . . . . . . . . . .
___________
Net spousal support . . . . . . . . . . . . . . . . . . . . . . . . ____________
Net employment insurance benefits . . . . . . . . . . . ____________
Net social assistance . . . . . . . . . . . . . . . . . . . . . . . ____________
Self-employment income
Gross _________Net . . . . . . . . . . . . . . . . . . . . . . . ____________
Other net income . . . . . . . . . . . . . . . . . . . . . . . . . . ____________
(Provide details
)
**
TOTAL MONTHLY INCOME . . . . . . . . . . . . . . . . . . . $_________(1)
$_________(2)
TOTAL MONTHLY INCOME OF
' $_________(3)
THE FAMILY UNIT ((1) + (2))
MONTHLY NON-DISCRETIONARY
EXPENSES
Child support payments . . . . . . . . . . . . . . . . . . . . . ____________
Spousal support payments . . . . . . . . . . . . . . . . . . . ____________
Child care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________
Health condition expenses . . . . . . . . . . . . . . . . . . . ____________
Fines/Penalties imposed by the court . . . . . . . . . . ____________
Expenses as a condition of employment . . . . . . . . ____________
Debts where stay has been lifted . . . . . . . . . . . . . ____________
Other expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________
(Provide details
)
TOTAL MONTHLY NON-
DISCRETIONARY EXPENSES . . . . . . . . . . . . . . . . . . $
(4)
$___________ (5)
TOTAL MONTHLY NON-DISCRETIONARY
' $
EXPENSES OF THE FAMILY UNIT ((4) + (5))
(6)
AVAILABLE MONTHLY INCOME
OF THE BANKRUPT ((1) - (4)) . . . . . . . . . . . . . . . . . . $_________ (7)
AVAILABLE MONTHLY INCOME
' $_________(8)
OF THE FAMILY UNIT ((3) - (6))
BANKRUPT’S PORTION OF THE AVAILABLE
MONTHLY FAMILY UNIT INCOME
' % _______(9)
((7) / (8) X 100))
**
If one or more members of the family unit have refused to divulge this information, please provide details as
required by section 10 of Directive 11R.
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