FORM 70.09C

No.

IN THE SUPREME COURT OF NOVA SCOTIA

(FAMILY DIVISION)

BETWEEN:

*[A. B.]


- and -


*[C. B.]

Applicant/Petitioner




Respondent

STATEMENT OF EXPENSES

OF *[name]

DATE PREPARED: *[date]

 

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

 

1.   The following are my current budgeted monthly expenses: (If you reside with another person with whom you share living expenses, list only your expenses, not the expenses paid by the person with whom you reside).

 


NOTE: ALL ITEMS ARE TO BE CONVERTED TO A MONTHLY AMOUNT

EXPENSES

MONTHLY BUDGETED EXPENSES

COMMENTS

 

1.    Rent/Mortgage

 

 

2 . Municipal Taxes

 

 

3.    Property - Fire Insurance

 

 

4.    Heat

 

 

5.    Electricity

 

 

6.    Water

 

 

7.    Telephone, Postage

 

 

8.    Cable

 

 

9.    House Repairs, Maintenance, Appliance &

       Furniture Repairs and Replacement

 

 

10.  Food

 

 

11.  Toiletries, Household Supplies

 

 

12.  Clothing

 

 

13.  Laundry and Dry-Cleaning

 

 

14.  Motor Vehicle:

(a)Payment

 

 

       (b) Gas

 

 

       (c) Maintenance/Repair

 

 

       (d) Insurance, License, Registration & Inspection

 

 

       (e) Parking & Tolls

 

 

15.  Taxis, Public Transportation

 

 

16.  Section 7 Child Related Expenses:

       (a) Child Care Expense (day-care or baby-sitting)

 

 

       (b) Children’s Medical or Dental Insurance Premiums

 

 

(c) Health Related Expenses

 

 

(d) Primary or Secondary School Expense

 

 

(e) Post Secondary School Expense

 

 

       (f)  Extracurricular Activities

 

 

17.  School Supplies, Tuition, Books

 

 

18.  Children’s Allowances and Activities

 

 

19.  Child Access Costs

 

 

20.  Hair and Grooming

 

 

21.  Life Insurance/Medical Insurance

 

 

22.  Drugs

 

 

23.  Dental

 

 

24.  Glasses

 

 

25.  Christmas, Birthdays, Events & Gifts

 

 

26.  Newspapers and Magazines

 

 

27.  Charitable Donations

 

 

28.  Holidays

 

 

29.  Entertainment

 

 

30.  Savings

 

 

31.  Child Support (paid for a child other than the child(ren) to whom this proceeding relates)

 

 

32.  Spousal Support (for a spouse other than a party to this proceeding)

 

 

33. Miscellaneous

 

 

34. Other -

 

 

35. Other -

 

 

SUB-TOTAL

 

 

Debt Payments:

 

 

36. 

 

 

37. 

 

 

38. 

 

 

SUB-TOTAL

 

 

39.  Income Source Deductions, excluding Income Tax

 

 

                        (1)   CPP

 

 

                        (2)   EI

 

 

                        (3)   Pension

 

 

                        (4)   Union Dues

 

 

                        (5)   Medical Plan

 

 

                        (6)   Other -

 

 

TOTAL EXPENSES

 

 

 

 

 

SUMMARY

 

 

Total Income Before Tax (from Statement of Income)

 

 

 

 

Less:    Total Expenses (from above)

 

 

Surplus (Deficit) Before Tax

 

 

Less:    Income Tax (Attach Calculations)

 

 

SURPLUS (DEFICIT)

 

 

 

 

 

 

 

 

 

 

 

 

To be completed if either party is making a claim for undue hardship pursuant to Section 10 of the Child Support Guidelines or spousal support.

2.    The following are the names, occupations or sources of income of all persons with whom I currently reside or with whom I share living expenses or from whom I receive an economic benefit as a result of living with that person. If you are making a claim for undue hardship, you must provide the following information. If you do not provide the following information your application for undue hardship may not be considered.

 

 

NAME

OCCUPATION OR SOURCE OF INCOME

1.    

 

2.    

 

3.    

 

 

SWORN TO at *[location], in the County of *[name of county], Province

of Nova Scotia, this *[date] day of

*[month], *[year], before me

 

 

________________________________

A Barrister, Notary or Commissioner of Oaths for the Province of Nova Scotia

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_______________________________

*[name]