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
Self Employed Income

SELF EMPLOYED: Please see the Self employed paper sheets provided to you at signup. These must be completed in ADDITION to this form.
Please describe "Other"
Bankrupt Monthly Income
Spouse's Monthly Income
Other Family Member's Monthly 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
Are you sure you want to submit? *

Yes
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