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

Coming into force September 18, 2009
(Section 68 and Subsection 102(3) of the Act; Rule 105(4))

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

(Title Form 1)

Original 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:

Monthly Income	Bankrupt/ Debtor	Other members of the family unit	Total
Net employment income
Net pension/annuities
Net child support
Net spousal support
Net employment insurance benefits
Net social assistance
Self-employment income
Gross Net
Other net income (Such as amounts received as damages for wrongful dismissal, as pay equity settlement, or that relate to workers' compensation) (Provide details )
Total Monthly Income	$(1)	$(2)*
Total Monthly Income of the Family Unit ((1) + (2))			$(3)
Monthly Non-Discretionary Expenses
Child support payments
Spousal support payments
Child care
Health condition expenses
Fines/penalties imposed by the Court
Expenses as a condition of employment
Debts where stay has been lifted
Other expenses (Provide details )
Total Monthly Non-Discretionary Expenses	$ (4)	$ (5)
Total Monthly Non-Discretionary Expenses of the Family Unit ((4) + (5))			$(6)
Available Monthly Income of the Bankrupt/Debtor ((1) - (4))	$ (7)
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)			% (9)

* If one or more members of the bankrupt's/debtor's family unit have refuse to divulge this information, please provide details as required by paragraph 6(3) of Directive No. 11R2.

Monthly discretionary expenses: (Family unit)

Housing expenses	Rent/mortgage/hypothec
	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 medical 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
	House
	Furniture/contents
	Life insurance
	Other
Payments	To the estate
	To secured creditor
	(Other than mortgage and vehicle)
	Other
Total Monthly Discretionary Expenses (Family Unit)		- $(10)
Monthly Surplus or (Deficit) Family Unit ((8) - (10))		=$(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:

 

Total amount bankrupt has agreed to pay monthly

(12)

Amount bankrupt has agreed to pay monthly to repurchase assets
(Provide details)

(13)

Residual amount paid into the estate ((12) - (13))

(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)

(15)

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: )

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

 

Dated at , this day of .

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