ONTARIO
Court file number
(Name of Court)
Form 27B: Statement of
Income from Income
at
Source
Court office address
Recipient(s)
Full legal name & address for service — street & number, municipality,
Lawyer’s name & address — street & number, municipality, postal
postal code, telephone & fax numbers and e-mail address (if any).
code, telephone & fax numbers and e-mail address (if any).
Payor
Full legal name & address for service — street & number, municipality,
Lawyer’s name & address — street & number, municipality, postal
postal code, telephone & fax numbers and e-mail address (if any).
code, telephone & fax numbers and e-mail address (if any).
1. My name is
(full legal name)
2.
I am
an income source of the payor.
an employee of an income source of the payor.
(Other; specify.)
OR
Neither I nor the organization for which I work is an income source of the payor for the following reasons:
there is no money owed to the payor on any basis mentioned in paragraph 3 below.
the payor has never worked for me or my organization.
the payor has worked for me or my organization but stopped working on
(date)
(Other; specify.)
Strike out paragraph 3 if you are not an income source.
3. I owe money to the payor on the following basis:
(check one or more boxes below)
wages or salary of $
per
overtime that, over the past 6 months, has amounted to $
commission, bonus, piece-work allowance or other performance-related payment that, over the past 6 months,
has amounted to $
benefits under an accident, disability or sickness plan that, over the past 6 months, has amounted to $
a disability, retirement or other pension of $
per
an annuity paying $
per
vacation pay/severance pay of $
(Other; specify.)
Signature
Date of signature
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FLR-27B-E (2005/09)