Financial Statement Page 2
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10Form 13.1: Financial Statement (Property and
(page 2)
Court File Number
Support Claims)
3.
I attach proof of my year-to-date income from all sources, including my most recent
(attach all that are applicable):
pay cheque stub
social assistance stub
pension stub
workers' compensation stub
employment insurance stub and last Record of Employment
statement of income and expenses/ professional activities (for self-employed individuals)
other (e.g. a letter from your employer confirming all income received to date this year)
4.
Last year, my gross income from all sources was $
(do not subtract any taxes that have been
deducted from this income).
5.
I am attaching all of the following required documents to this financial statement as proof of my income over the past
three years, if they have not already been provided:
•
a copy of my personal income tax returns for each of the past three taxation years, including any materials that were
filed with the returns. (Income tax returns must be served but should NOT be filed in the continuing record, unless
they are filed with a motion to refrain a driver’s license suspension.)
•
a copy of my notices of assessment and any notices of reassessment for each of the past three taxation years;
•
where my notices of assessment and reassessment are unavailable for any of the past three taxation years or where
I have not filed a return for any of the past three taxation years, an Income and Deductions printout from the Canada
Revenue Agency for each of those years, whether or not I filed an income tax return.
Note: An Income and Deductions printout is available from Canada Revenue Agency. Please call customer service
at 1-800-959-8281.
OR
I am an Indian within the meaning of the Indian Act (Canada) and I have chosen not to file income tax returns for the
past three years. I am attaching the following proof of income for the last three years
(list documents you have provided):
(In this table you must show all of the income that you are currently receiving whether taxable or not.)
Income Source
Amount Received/Month
1. Employment income (before deductions)
$
2. Commissions, tips and bonuses
$
)
3. Self-employment income (Monthly amount before expenses: $
$
4. Employment Insurance benefits
$
5. Workers' compensation benefits
$
6. Social assistance income (including ODSP payments)
$
7. Interest and investment income
$
8. Pension income (including CPP and OAS)
$
9. Spousal support received from a former spouse/partner
$
10. Child Tax Benefits or Tax Rebates (e.g. GST)
$
11. Other sources of income (e.g. RRSP withdrawals, capital gains)
(*attach Schedule A and
$
divide annual amount by 12)
12. Total monthly income from all sources:
$
13. Total monthly income X 12 = Total annual income:
$
Page 2 of 10
FLR-13.1-E (2015/01)
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