Income and Expense Statement
For which month?
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January
February
March
April
May
June
July
August
September
October
November
December
Which Year?
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Client Name
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First Name
Last Name
Has your marital status changed this month?
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Yes
No
Current Marital Status
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Single
Married
Common Law
Separated
Divorced
Widowed
Previous Marital Status
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Single
Married
Common Law
Separated
Divorced
Single
Widowed
Is your spouse disclosing their income?
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Yes
No
Spouses Name
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First Name
Last Name
Is your spouse also in bankruptcy with us?
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Yes
No
Have the # of family members changed this month?
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Yes
No
Why have they changed?
Birth of a child, child left home, death in the family
# of Household Members
Has your address changed this month?
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Yes
No
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
If yes, please attach your self employment report:
*
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Are you a T4 employed? (Full or Part time)
Yes
No
Employer
Occupation
Has your employer changed this month?
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Yes
No
Employer
Occupation
Income Sources
Bankrupt
Spouse
Other Family Members
Notes / Description
Employment Income
Pension
Child Support
Spousal Support
Employment Insurance benefits
Social Assistance
Child Tax Benefit
Gifts
Other Income
Self Employed Income
Bankrupt Monthly Income
Spouse's Monthly Income
Other Family Member's Monthly Income
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Monthly Family Non-Discretionary Expenses
Non-Discretionary Expenses
Bankrupt Spent
Spouse Spent
Other Family Member 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
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Personal Monthly Expenses
Spent
Notes/Description
Housing Expenses:
Rent/Mortgage
Property Taxes/Condo Fees
Heating/Gas/Oil
Telephone
Cable
Hydro
Water
Furniture
Other
Personal Expenses:
Smoking
Alcohol
Dining/ Lunches/ Restaurants
Entertainment/ Sports
Gifts/ Charitable Donations
Allowances
Other
Non-Recoverable Medial Expenses:
Prescriptions
Dental
Other
Living Expenses:
Food/ Grocery
Laundry/ Dry cleaning
Grooming/ Toiletries
Clothing
Other
Transportation Expenses:
Car Lease/ Payments
Repair/ Maintenance/ Gas
Public Transportation
Other
Insurance Expenses:
Vehicle Insurance
House Insurance
Furniture/ Contents Insurance
Life Insurance
Other
Payments:
Payments to the Estate
Payments to secured creditor (other)
Other
Sub Total Discretionary Expenses
Total Family Income
Total Expenses
Net Income
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Attach Documents
Please attach your pay-stubs for this month
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Please attach back statements for all of your accounts for this month
*
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Bankrupt Signature
Clear
Are you sure you want to submit?
*
Yes
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Submit
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