FORM 70.09B

STATEMENT OF SPECIAL OR EXTRAORDINARY EXPENSES

OF *[name]

DATE PREPARED: *[date]

I, *[name], of *[location], Province of Nova Scotia, make oath and say that:

1.    I am claiming an amount to cover special or extraordinary expenses for one or more of the following reasons (indicate which of the following you are claiming):

       ☐  a)  child care expenses incurred as a result of my employment, illness, disability or education or training for employment;

       ☐  b)  that portion of the medical and dental insurance premiums attributable to the child;

       ☐ c)    health-related expenses that exceed insurance reimbursement by at least $100 annually, including orthodontic treatment, professional counselling provided by a psychologist, social worker, psychiatrist or any other person, physiotherapy, occupational therapy, speech therapy and prescription drugs, hearing aids, glasses and contact lenses;

       ☐ d)    extraordinary expenses for primary or secondary school education or for any educational programs that meet the child’s particular needs;

       ☐  e)  expenses for post-secondary education; or

       ☐  f)   extraordinary expenses for extracurricular activities.

2.    The child’s name that each expense relates to, the details of each type of expense I am claiming, and the total amount of each expense per month are:

            Child’s Name                        Details of Each Expense                      Total Amount of Expense

       1. ___________________        _________________________      $________ per month

       2. ___________________        _________________________      $________ per month

       3. ___________________        _________________________      $________ per month

       4. ___________________        _________________________      $________ per month

       5. ___________________        _________________________      $________ per month

3.    I attach receipts or other documentation which show the amount of the expenses I am claiming for each child.

4.    I am unable to obtain receipts or other documentation, for the following reasons:

       __________________________________________________________________________

       __________________________________________________________________________

       __________________________________________________________________________

       _____________________________________________________________________________

5.    I am eligible to claim or I receive the following subsidies, benefits or income tax deductions or credits relating to the above expenses: (provide details)

       __________________________________________________________________________

       ____________________________________________________________________________

       __________________________________________________________________________

       __________________________________________________________________________