Income and Expense Statement

Income and Expense Statement
For which month?
Which Year?
Client Name

First Name Last Name
Marital Status
Has your marital status changed this month?

Yes No
Previous Marital Status
Is your spouse disclosing their income?

Yes No
Spouses Name

First Name Last Name
Is your spouse also in bankruptcy with us?

Yes No
Have the # of family members changed this month?

Yes No
Why have they changed?
Birth of a child, child left home, death in the family
# of Household Members
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Has your address changed this month?

Yes No
Prior Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone number

Area Code Phone Number
Additional phone number

Area Code Phone Number
Email
example@example.com
Regular Income
Are you self employed?

Yes No
Are you a T4 employed? (Full or Part time)

Yes No
Employer
Occupation
Has your employer changed this month?

Yes No
Employer
Occupation

Income Sources

Bankrupt

Spouse

Other Family Member

Employement Income

Pension

Child Support

Spousal Support

Employment Insurance benefits

Social Assistance

Child Tax Benefit

Gifts

Other Income

Please describe "Other"
Bankrupt Monthly Income
Spouse's Monthly Income
Other Family Member's Monthly Income

Self Employed Income
Instructions
The month will run from the 1st-31st of each month.

Business Expenses are any expenses that you have in the operation of your business.

Some expenses are 100% business expenses like office supplies, or repairs of business equipment.

Other expense might only be a combination of both personal and business expenses.

Example: You use your vehicle for both 60% personal use and 40% business use. Your monthly vehicle expenses are $1000.00.

$1000.00 x .40 = $400

$400.00 Would be your total amount for Business Vehicle Expenses.

GST: If you have a GST number you will need to set aside 5% of your gross earnings to forward to the CRA

Income Tax: We will assume a 25% tax rate
Enter only your business income
Total Gross Business income for the month from all sources:
Enter only your business expenses

Please describe "Other"
Do you have a GST number and pay GST

Yes No
GST Number
Income without GST
Total GST Payable
Business Income
Estimated Income Tax Payable (25%)
NET BUSINESS INCOME

Monthly Family Non-Discretionary Expenses

Non-Discretionary Expenses

Bankrupt Spent

Spouse Spent

Notes/Description

Child Support Payment

Spousal Support Payment

Child Care

Medical Condition Expenses

Fines/Penalties imposed by the court

Expenses as a condition of employment

Debts where the stay has been lifted

Bankrupt ND Expenses
Spouse ND Expenses

Personal Monthly Expenses

Housing Expenses

Spent

Notes/Description

Rent/Mortgage

Property Taxes/Condo Fees

Heating/Gas/Oil

Telephone

Cable

Hydro/Power

Water

Furniture

Other

Please describe "Other"
Sub Total Housing Expenses

Personal Expenses

Spent

Notes/Description

Smoking

Alcohol

Dining Out/Lunches

Entertainment/Sports

Gifts/Donations

Allowance

Other

Please describe "Other"
Sub Total Personal Expenses

Non-Recoverable Medical Expenses

Spent

Notes/Description

Prescriptions

Dental

Other

Please describe "Other"
Sub Total NR Medical Expenses

Living Expenses

Spent

Notes/Description

Food/Groceries

Laundry/Dry Cleaning

Grooming/Toiletries

Clothing

Other

Please describe "Other"
Sub Total Living Expenses

Transportation Expenses

Spent

Notes/Description

Car/Lease Payments

Repair/Maintenance/Gas

Public Transportation

Other

Please describe "Other"
Sub Total Transportation Expenses

Insurance Expenses

Spent

Notes/Description

Vehicles

House

Furniture/Contents

Life

Other

Please describe "Other"
Sub Total Insurance Expenses

Payments Expenses

Spent

Notes/Description

To BNA

To secured creditor (not house and car)

Spouses debt payments

Other

Please describe "Other"
Sub Total Payments Expenses
Total Family Income
Total Expenses
Net Income (Should be 0!)

Attach Documents
Please attach your pay-stubs for this month

Browse Files

Cancel of
Please attach back statements for all of your accounts for this month

Browse Files

Cancel of
Bankrupt Signature

Clear
Should be Empty: