Income and Expense Form

Due by the 12th of the following month.

Date

Year

Month

Day

Monthly income and expense statement

Debtor

First

Last

Address

Street Address

Address Line 2

City

Province

Postal Code

Spouse's First name

Last name

Number of dependents

Ages of dependents

Employer

If you are self employed please write "self"

Spouse's Employer

If they are self employed please write "self"

Monthly gross income from all sources

Myself – Gross

Spouse – Gross

Monthly net wages from all sources

Myself – Net

Spouse – Net

Child tax benefit

Child tax benefit (myself)

Other sources of income

Value of above selection (myself)

Value of above selection (spouse)

Total net monthly income

Attach any pay statement

Accepted file types: jpg, pdf, doc, jpeg, png, docx, Max file size: 16MB

Monthly (family) living expenses

Do not upload receipts, but please retain

Housing

Rent/Mortgage

Utilities

Household Maintenance

Telephone Service

Taxes/Condo Fees

Other

Sub total - Housing

Personal

Food/Toiletries

Drycleaning

Baby Supplies

Daycare

Clothing

Grooming

Entertainment

Alcohol

Tobacco

School Fees

Alimony/Support

Other

Sub total - Personal

Medical

Drugs

Dentist

Other

Attach Receipts

Accepted file types: jpg, jpeg, pdf, doc, docx, png, Max File Size:16MB

Sub Total - Medical

Insurance

Life

Auto

Blue Cross

House/Contents

Other

Sub total - Insurance

Travel

Vehicle Payment

Bus/Carpool

Gas/Maintenance

Other

Sub total - Travel

Totals

Total monthly expenses

Surplus income deficit

Payment to trustee

Comments

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Income and Expense Form

Monthly income and expense statement

Monthly gross income from all sources

Monthly net wages from all sources

Child tax benefit

Monthly (family) living expenses

Personal

Medical

Insurance

Travel

Totals

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