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PERSONAL INCOME AND EXPENSE REPORT
Calendar Month: _________________________________
Name: __________________________________________
If we need to contact you, what is the best way? _____________ Has any of your contact information changed? Y / N
Home Phone:___________________________________________ Cell Phone:__________________________________
Email: _________________________________________________ Other: ______________________________________
Did you move this month? Y / N
Did your employer change this month? Y / N
(If you moved or switched employers, please write the new information below:)
________________________________________________________________________________________________________
I confirm that there are ___________ people in my family unit as defined by the Superintendent’s Standards.
INCOME Bankrupt Spouse & other family members
Take-home pay from employment (attach pay stubs) ____________ ____________
Add back deductions for RRSPs, savings, extra taxes etc. ____________ ____________
EI Benefits, Pensions, Old Age Security (attach bank statement) ____________ ____________
Child Tax Benefit & Universal Child Benefit (attach bank statement
or government notice) ____________ ____________
Other income (describe)_____________________________ ____________ ____________
TOTAL INCOME FOR MONTH $ + $ = $_____________
EXPENSES
NON-DISCRETIONARY EXPENSES (attach copies of receipts or proof of payments)
Child or spousal support payments ____________
Medical/dental expenses/prescription drugs ____________
Child care (describe) ____________
Other non-discretionary expenses (eg: fines from before the date of bankruptcy) ____________
DISCRETIONARY EXPENSES (do NOT attach receipts)
Housing: Rent or mortgage payment ____________
Property taxes/condo fees ____________
Natural Gas ____________
Telephone, Cable, Internet ____________
Electricity ____________
Personal: Tobacco ____________
Alcohol ____________
Charitable donations/tithing/gifts ____________
Entertainment/sports ____________
Living: Food/groceries ____________
Dining out/coffee or lunch at work ____________
Grooming / toiletries/ laundry / dry cleaning ____________
Clothing ____________
Transportation: Car lease/payments ____________
Gas/repairs/maintenance ____________
Public transportation/parking ____________
Other ____________
Insurance: Vehicle ____________
House / Furniture / Contents ____________
Life / Medical/ Disability ____________
Miscellaneous: To secured creditors (other than mortgage and vehicle) ____________
Other (describe) ____________
Payments to Trustee as agreed ____________
TOTAL EXPENSES FOR MONTH $___________
INCOME LESS EXPENSES = SAVINGS!!! $___________
The above is an accurate statement of my income and expenses as witnessed by my signature.
Signature__________________________________________________ Date _____________________________________
YOU MUST FULLY COMPLETE EVERY LINE ON THIS FORM. INCOMPLETE FORMS WILL BE RETURNED.
THIS STATEMENT MUST BE FORWARDED TO OUR OFFICE BY THE _____ OF THE FOLLOWING MONTH.