FORM 70.09A

STATEMENT OF INCOME

OF (Name)

DATE PREPARED:

            I, , of , Province of Nova Scotia, make oath and say that:

1.          The following chart converts my gross income ( as stated on my pay stub or other document filed or attached) to a monthly figure. (If you have two income sources, use one chart for each source.)

First Income Source: _________________________________ (Name of Source)

Second Income Source: _________________________________ (Name of Source)

2.         The following is a statement of my current monthly income from all sources:

       3.       Attached are true copies of my personal income tax returns filed with Canada Revenue Agency for the three most recent taxation years.

       4.       Attached are true copies of Notices of Assessment (or Re-Assessment) issued by Canada Revenue Agency for each of the three most recent taxation years.

       5.       THE FOLLOWING ITEMS MARKED WITH AN “X’ APPLY TO ME:

                  □          I AM AN EMPLOYEE:

Attached is a true copy of my two most consecutive recent statements of earnings or pay stubs indicating my total earnings paid in the year to date, including overtime (or alternatively, a letter from my employer setting out my annual salary or remuneration, my earnings to date for this year, including overtime).

                  □          I AM UNEMPLOYED:

Attached is a statement of my income to date this year from (include particulars of all income received by way of employment insurance benefits, social assistance, pension income, Workers’ Compensation, disability or such other benefits or income as may apply. If a statement of income is not available, provide a letter from the applicable source of income stating the required information).

                  □          I AM SELF-EMPLOYED:

I am self-employed and attached are:

                                          (i)        true copies of the financial statements of my business or professional practice (other than partnership) for the three most recent taxation years; and

                                          (ii)       a statement showing a breakdown of all salaries, wages, management fees or other payments or benefits paid to, or on behalf of, persons or corporations with whom I do not deal at arms length.

                                          □          I AM A MEMBER OF A PARTNERSHIP:

I am a partner in the partnership known as __________________[name of Partnership] and attached hereto is confirmation of my current income and draw from that partnership and my capital in the partnership for the three most recent taxation years.

                                          □          I CONTROL A CORPORATION:

                                          (i)        Attached are true copies of the financial statements for the corporation ___________________[name of corporation], in which I have a controlling interest, for the three most recent taxation years. [Where a party controls a corporation, the financial statements for the three most recent taxation years for that corporation must be provided as well as the financial statements for that company’s subsidiaries].

                                          (ii)       Attached is a statement showing a breakdown of all salaries, wages, management fees and other payments or benefits paid to, or on behalf of, persons or corporations with whom the corporation, and every related corporation does not deal at arm’s length.

                                          □          I AM A BENEFICIARY UNDER A TRUST:

Attached is a true copy of the trust settlement agreement of which I am a beneficiary as well as true copies of the three most recent financial statements of the trust.

                                          □           I AM AN ADMINISTRATOR OR A TRUSTEE OF A TRUST