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

For persons to which the 2009 amendments apply

PDF version

Form 65

22 KB, 1 page

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


(Title Form 1)

Check box if this is an original Original Checkbox for amended Amended

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

Income and Expenses
Monthly Income Bankrupt/
Debtor
Other members of the family unit Total
Net employment income Space to insert net employment income of bankrupt/debtor empty cell empty cell
Net pension/annuities Space to insert net pension/annuities of bankrupt/debtor empty cell empty cell
Net child support Space to insert net child support of bankrupt/debtor empty cell empty cell
Net spousal support Space to insert net spousal support of bankrupt/debtor empty cell empty cell
Net employment insurance benefits Space to insert net employment insurance benefits of bankrupt/debtor empty cell empty cell
Net social assistance Space to insert net social insurance of bankrupt/debtor empty cell empty cell
Self-employment income   empty cell empty cell
Gross Space to insert gross self-employment incomeNet Space to insert net self-employment income empty cell  empty cell 
Other net income
(Such as amounts received as damages for wrongful dismissal, as pay equity settlement, or that relate to workers' compensation)
( details Space to insert details of other net income)
Space to insert other net income empty cell  empty cell 
Total Monthly Income $Space to insert total monthly income amount of bankrupt/debtor(1) $Space to insert total monthly income amount of other members of the family unit(2)Footnote a empty cell 
Total Monthly Income of the Family Unit ((1) + (2)) empty cell  empty cell  $Space to insert total monthly income of the family unit ((1)+(2))(3)
Monthly Non-Discretionary Expenses
Child support payments Space to insert child support payments of bankrupt/debtor empty cell empty cell
Spousal support payments Space to insert spousal support payments of bankrupt/debtor empty cell empty cell
Child care Space to insert child care of bankrupt/debtor empty cell empty cell
Health condition expenses Space to insert health condition expenses of bankrupt/debtor empty cell empty cell
Fines/penalties imposed by the Court Space to insert fines/penalties imposed by the Court of bankrupt/debtor empty cell empty cell
Expenses as a condition of employment Space to insert expenses as a condition of employment of bankrupt/debtor empty cell empty cell
Debts where stay has been lifted Space to insert debts where stay has been lifted of bankrupt/debtor empty cell empty cell

Other expenses
( details Space to insert details of other expenses)

Space to insert other expenses of bankrupt/debtor empty cell empty cell
Total Monthly Non-Discretionary Expenses $Space to insert total monthly non-discretionary expenses of bankrupt/debtor (4) $Space to insert total monthly non-discretionary expenses of other members of the family unit (5) empty cell
Total Monthly Non-Discretionary Expenses of the Family Unit ((4) + (5)) empty cell empty cell $Space to insert total monthly non-discretionary expenses of the family unit ((4)+(5)) total(6)
Available Monthly Income of the Bankrupt/Debtor ((1) - (4)) $Space to insert amount for available monthly income of the bankrupt/debtor ((1)-(4)) (7) empty cell empty cell
Available Monthly Income of the Family Unit ((3) - (6)) empty cell empty cell $Space to insert total amount for available monthly income of the family unit ((3)-(6))(8)
Bankrupt's/Debtor's Portion of the Available Monthly Income of the Family Unit ((7) / (8) X 100) empty cell  empty cell  % Space to insert total percentage of the bankupt/debtorès portion of available income of the family unit ((7)/(8)x100)(9)
Monthly discretionary expenses: (Family unit)
Housing expenses Rent/mortgage/hypothec Space to insert rent/mortgage/hypothec expenses
Property taxes/condo feesSpace to insert property taxes/condo fees
Heating/gas/oil Space to insert heating/gas/oil expenses
Telephone Space to insert telephone expenses
Cable Space to insert cable expenses
Hydro Space to insert hydro expenses
Water Space to insert water expenses
Furniture Space to insert furniture expenses
Other Space to insert other housing expenses
Personal expenses Smoking Space to insert smoking expenses
Alcohol Space to insert alcohol expenses
Dining/lunches/restaurants Space to insert dining/lunches/restaurants expenses
Entertainment/sports Space to insert entertainment/sports expenses
Gifts/charitable donations Space to insert gifts/charitable donations
Allowances Space to insert allowances expenses
Other Space to insert other personal expenses
Non-recoverable medical expenses Prescriptions Space to insert prescriptions expenses
Dental Space to insert dental expenses
Other Space to insert other non-recoverable medical expenses
Living expenses Food/grocery Space to insert food/grocery expenses
Laundry/dry cleaning Space to insert laundry/dry cleaning expenses
Grooming/toiletries Space to insert grooming/toiletries expenses
Clothing Space to insert clothing expenses
Other Space to insert other living expenses
Transportation expenses Car lease/payments Space to insert car lease/payments
Repair/maintenance/gas Space to insert repair/maintenance/gas expenses
Public transportation Space to insert public transportation expenses
Other Space to insert other transportation expenses
Insurance expenses Vehicle Space to insert vehicle insurance expenses
House Space to insert house insurance expenses
Furniture/contents Space to insert furniture/contents insurance expenses
Life insurance Space to insert life insurance expenses
Other Space to insert other insurance expenses
Payments To the estate Space to insert payments to the estate
To secured creditor Space to insert payments to secured creditor
(Other than mortgage and vehicle) Space to insert payments other than mortgage and vehicle
Other Space to insert other payments
Total Monthly Discretionary Expenses (Family Unit) - $Space to insert amount for total monthly discretionary expenses (family unit)(10)
Monthly Surplus or (Deficit) Family Unit ((8) - (10)) =$Space to insert amount for monthly surplus or (deficit) family unit ((8)-(10))(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 number
empty cell 
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
( details) Space to insert details
Space to insert amount bankrupt has agreed to pay monthly to repurchase assets (13)
Residual amount paid into the estate ((12) - (13))
Space to insert residual amount paid into the estate (14)

Payments required by Directive No. 11R2 (Surplus Income)

Monthly amount required by Directive No. 11R2 (Surplus Income) based on percentage established on line (9)
Space to insert monthly amount required by Directive No. 11R2 (15)
Difference between (14) and (15)
Space to insert difference between (14) and (15) (16)
Other applicable comments (If amount on line (14) is less than amount on line (15),
explain why the required payments are not being made: Space to insert other applicable comments)

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

empty cell 

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

Space to insert signature of trustee
Licensed Insolvency Trustee
Space to insert signature of bankrupt/debtor
Bankrupt/Debtor

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.

Important Notices

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

The HTML version of this Form is not the official version. In the event of an inconsistency between the HTML and PDF versions of this Form, the PDF version prevails. Users are required to exercise due diligence with respect to the HTML version.

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