Financial Statement Page 3
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10Form 13.1: Financial Statement (Property and
(page 3)
Court File Number
Support Claims)
14.
Other Benefits
Provide details of any non cash benefits that your employer provides to you or are paid for by your business such as medical insurance
coverage, the use of a company car, or room and board.
Item
Details
Yearly Market Value
$
$
$
$
PART 2: EXPENSES
Expense
Monthly Amount
Expense
Monthly Amount
Automatic Deductions
Transportation
CPP contributions
$
Public transit, taxis
$
EI premiums
$
Gas and oil
$
Income taxes
$
Car insurance and license
$
Employee pension contributions
$
Repairs and maintenance
$
Union dues
$
Parking
$
SUBTOTAL
$
Car Loan or Lease Payments
$
Housing
SUBTOTAL
$
Rent or mortgage
$
Health
Property taxes
$
Health insurance premiums
$
Property insurance
$
Dental expenses
$
Condominium fees
$
Medicine and drugs
$
Repairs and maintenance
$
Eye care
$
SUBTOTAL
$
SUBTOTAL
$
Utilities
Personal
Water
$
Clothing
$
Heat
$
Hair care and beauty
$
Electricity
$
Alcohol and tobacco
$
Page 3 of 10
FLR-13.1-E (2015/01)
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