Form I - Financial Information
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9FINANCIAL
INFORMATION
Form I
1. My information
Name of the person completing this Form (First Middle Last):
Date this Form was completed (YYYY/MM/DD):
2. My financial circumstances
My total annual income (before tax and other deductions) for the current year will be approximately
. Proof of my income for the current year is provided below. I have included:
details of the income sources checked below including supporting documents for each source of income
identified (including start and end dates); and
the three most recent statements of earnings or income (pay stubs) for each source of income identified.
Current year (
)
Start Date
End Date
Year to Date
Income
I am an employee. I have attached statements
showing my total earnings from all employment
(YYYY/MM/DD)
(YYYY/MM/DD)
sources for this year, to date, including overtime. If this
information is not shown on my pay stubs, I have
attached a statement(s) or letter(s) from my
employer(s) with that information, including my rate of
annual pay.
I am receiving Workers Compensation benefits. My
three most recent WCB benefits statements are
(YYYY/MM/DD)
(YYYY/MM/DD)
attached.
I am receiving Employment Insurance benefits. My
three most recent EI benefits statements are attached.
(YYYY/MM/DD)
(YYYY/MM/DD)
I am receiving Social or Income Assistance. I have
attached a statement showing the amount I received.
(YYYY/MM/DD)
(YYYY/MM/DD)
I am receiving Disability insurance. I have attached a
statement showing the amount I received.
(YYYY/MM/DD)
(YYYY/MM/DD)
I am Self-employed.
(YYYY/MM/DD)
(YYYY/MM/DD)
I have attached the financial statements for the three most recent taxation years of my business or
professional practice, other than a partnership, and a statement showing a breakdown of salaries,
wages, management fees, or other payments or benefits paid to, or on behalf of, persons or
corporations with whom I do not deal at arm’s length.
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