Form 65 — Monthly Income and Expense Statement of the Bankrupt and the Family Unit and Information (or Amended Information) Concerning the Financial Situation of the Individual Bankrupt

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(Section 68 and Subsection 102(3) of the Act and Rule 105(4))

This form may not be completed online. It is provided here for reference purposes only.

(Title Form 1)

The information concerning the monthly income and expense statement of the bankrupt and the family unit, the financial situation of the bankrupt and the bankrupt's obligation to make payments required under section 68 of the Act to the estate of the bankrupt are as follows:

Monthly Income Statement of the Bankrupt
Monthly Income Bankrupt Other members of the family unit Total

Footnotes

  1. ** If one or more members of the family unit have refused to divulge this information, please provide details as required by section 10 of Directive 11R. (back to footnote reference **)
Net employment income Space to insert net employment income    
Net pension/Annuities Space to insert income from net pension/Annuities    
Net child support Space to insert income from Net child support    
Net spousal support Space to insert income from Net spousal support    
Net employment insurance benefits Space to insert income from Net employment insurance benefits    
Net social assistance Space to insert income from Net social assistance    
Self-employment income - Net
Gross Space to insert gross Self-employment income		 Space to insert net self-employment income    
Other net income
(Provide details Space to insert income from )		 Space to insert Other net income    
Total Monthly Income $Space to insert Total Monthly Income (1) (1) $Space to insert Total Monthly Income (2) (2)Footnote **  
Total Monthly Income of the Family Unit ((1) + (2)) arrow$Space to insert Total Monthly Income of the Family Unit(3)
Monthly non-Discretionary Expenses
Monthly Expenses Bankrupt Other members of the family unit Total
Child support payments Space to insert Child support payments    
Spousal support payments Space to insert Spousal support payments    
Child care Space to insert expenses from Child care    
Health condition expenses Space to insert Health condition expenses    
Fines/Penalties imposed by the court Space to insert expenses from Fines/Penalties imposed by the court    
Expenses as a condition of employment Space to insert expenses as a condition of employment    
Debts where stay has been lifted Space to insert Debts where stay has been lifted    
Other expenses
(Provide details Space to insert details of other expenses)		 Space to insert other expenses    
Total Monthly non-Discretionary Expenses $Space to insert Total Monthly non-Discretionary Expenses (4)(4) $Space to insert total monthly non-discretionary expenses (5)(5)  
Total Monthly non-Discretionary Expenses of the Family Unit ((4) + (5)) arrow$Space to insert total monthly non-discretionary expenses of the family unit ((4) + (5))(6)
Available Monthly Income of the Bankrupt ((1) - (4)). $Space to insert Available Monthly Income of the Bankrupt ((1) - (4)) (7)    
Available Monthly Income of the Family Unit ((3) - (6)) arrow$Space to insert Available Monthly Income of the Family Unit ((3) - (6))(8)
Bankrupt's Portion of the Available Monthly Family Unit Income ((7) / (8) X 100)) arrow%Space to insert Bankrupt's Portion of the Available Monthly Family Unit Income ((7) / (8) X 100))(9)
Monthly Discretionary Expenses: (Family unit)
Housing expenses Living expenses
  Rent/Mortgage/Hypothec Space to insert expenses for Rent/Mortgage/Hypothec   Food/Grocery Space to insert expenses for Food/Grocery
  Property taxes/Condo fees Space to insert expenses for Property taxes/Condo fees   Laundry/Dry cleaning Space to insert expenses for Laundry/Dry cleaning
  Heating/Gas/Oil Space to insert expenses for Heating/Gas/Oil   Grooming/Toiletries Space to insert expenses for Grooming/Toiletries
  Telephone Space to insert expenses for Telephone   Clothing Space to insert expenses for Clothing
  Cable Space to insert expenses for Cable   Other Space to insert other living expenses
  Hydro Space to insert expenses for Hydro Transportation expenses
  Water Space to insert expenses for Water   Car lease/Payments Space to insert expenses for Car lease/Payments
  Furniture Space to insert expenses for Furniture   Repair/ Maintenance/Gas Space to insert expenses for Repair/ Maintenance/Gas
  Other Space to insert other housing expenses   Public transportation Space to insert expenses for Public transportation
Personal expenses   Other Space to insert expenses for other transportation
  Smoking Space to insert expenses for Smoking Insurance expenses
  Alcohol Space to insert expenses for Alcohol   Vehicle Space to insert expenses for Vehicle
  Dining/Lunches/Restaurants Space to insert expenses for Dining/Lunches/Restaurants   House Space to insert expenses for House
  Entertainment/Sports Space to insert expenses for Entertainment/Sports   Furniture/Contents Space to insert expenses for Furniture/Contents
  Gifts/Charitable donations Space to insert expenses for Gifts/Charitable donations   Life insurance Space to insert expenses for Life insurance
  Allowances Space to insert expenses for Allowances   Other Space to insert expenses for other Insurance expenses
  Other Space to insert other personal expenses Payments
Non-recoverable medical expenses   To the estate Space to insert payments to the estate
  Prescriptions Space to insert expenses for Prescriptions   To secured creditor Space to insert payments to secured creditor
  Dental Space to insert dental expenses   (Other than mortgage and vehicle) Space to insert payments (other than mortgage and vehicle)
  Other Space to insert other non-recoverable medical expenses   Other Space to insert other payments
Total Monthly Discretionary Expenses (Family Unit) - $Space to insert Total Monthly Discretionary Expenses (10)
Monthly Surplus or (Deficit) Family Unit ((8) - (10)) = $Monthly Surplus or (Deficit) (11)

Information (or Amended Information) Concerning the Financial Situation of the Individual Bankrupt

Payments to the estate as per agreement

Number of persons in household family unit, including bankrupt: Space to insert income from number of persons in household family unit

Total amount bankrupt has agreed to pay monthly Space to insert Total amount bankrupt has agreed to pay monthly(12)

Amount bankrupt has agreed to pay monthly to repurchase assets Space to insert amount to repurchase assets(13)
(provide details) Space to insert income from details on amount to repurchase assets

Residual amount paid into the estate ((12) - (13)) Space to insert Residual amount paid into the estate(14)

Payments required by the Directive on Surplus Income

Monthly amount required by the Directive on Surplus Income based on percentage established on line (9) Space to insert monthly amount required on surplus income(15)

Difference between amounts at lines (14) and (15) Space to insert difference between amounts at lines (14) and (15)(16)

Other applicable comments: Space to insert other applicable comments
( If amount at line (14) is less than amount at line (15), explain why the required payments are not being made: Space to insert income from )

Amendment or material change: (If the information relates to a material change or an amendment, provide details: Space to insert amendment or material change)

Dated at Space to insert city , this Space to insert day of month day of Space to insert month Space to insert income year.

Space to insert trustee's signature
Trustee
Space to insert Bankrupt's Signature
Bankrupt

Notes: In a joint assignment, only one form is required and each debtor's monthly income and non-discretionary expenses have to be explained in detail.

If a copy of this Form is sent electronically by means such as email, the name and contact information of the sender, prescribed in Form 1.1, must be added at the end of the document.

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