FORM 70.09D

STATEMENT OF UNDUE HARDSHIP CIRCUMSTANCES

OF *[name]

DATE PREPARED: [date]

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

1.         I am claiming undue hardship on the basis of one or more of the following circumstances (indicate which of the following you are claiming):

☐       a)     I am responsible for an unusually high level of debts, which I had reasonably incurred to support myself, the other party and our child or children prior to our separation;

☐       b)     I am responsible for an unusually high level of debts, which I have reasonably incurred to earn a living;

☐       c)     I have unusually high expenses in relation to exercising access to my child;

☐     d)     I have a legal duty under a judgment, order or written separation agreement to support any person (other than the child(ren) to whom this proceeding relates);

☐       e)     I have a legal duty to support a dependent child in my household (other than the child(ren) to whom this proceeding relates);

☐       f)      I have a legal duty to support an adult person who is unable, by reason of illness, disability or other cause, to obtain the necessaries of life; or

☐       g)     I have some other undue hardship circumstance (be as specific as possible):

2. Residing with me as part of my household are the following individuals (in the case of the adults, also include their gross annual incomes for the past year):

            (a) Spouse or Partner:

            Name ___________________     Gross annual income: __________________

            (b) Any person (including a child the age of majority or over) who shares living expenses with me or from whom I otherwise receive an economic benefit as a result of living together:

            Name ___________________     Gross annual income: __________________

            Name ___________________     Gross annual income: __________________

            (c) Any child or children who reside(s) with me:

            Child’s Full Name ___________________   Date of Birth: __________________

            Child’s Full Name ___________________   Date of Birth: __________________

3.         Attached are true copies of the Notice of Assessment and Income Tax Return for the preceding year *[year] for each of the individuals listed in paragraph 2 above.

4.         Attached are true copies of the last two consecutive income statements (for example, pay stubs, Employment Insurance stubs, social assistance stub) or, instead, a letter from the employer (or income provider) confirming gross income year-to-date for the current year*[year] for each of the individuals listed in paragraph 2 above.

5. I would suffer undue hardship in paying the required amount of child support because:

6.         I request that the court deduct the following annual amount(s) which I am relying upon as a factor that has caused my undue hardship; [Note: Do not list any amount attributable to the support of any member (including any child) of the household that is not incurred due to a disability or serious illness of that member and do not list any amount listed in paragraph 7]:

            Factor: Annual Amount:

            Factor: Annual Amount:

7.         (a) I request that the court deduct the following annual amount(s) which I pay as support or maintenance pursuant to a judgment, order or written separation agreement [Note: Do not list any amount already listed in paragraph 6]:

            Annual Amount:     Date of Judgment, Order or Agreement:

            Annual Amount:     Date of Judgment, Order or Agreement:

(b) Attached is a certified copy of each of the judgments, orders or written separation agreements listed in paragraph 7(a) above.

8.         (a) I receive the following annual amount of child support or maintenance for any child under a judgment, order or written separation agreement:

            Annual Amount:     Date of Judgment, Order or Agreement:

            Annual Amount:     Date of Judgment, Order or Agreement:

(b) Attached is a certified copy of each of the judgments, orders or written separation agreements listed in paragraph 8(a) above.

9.         I understand that my claim of undue hardship must be denied by the court if my household standard of living is higher than the household standard of living of the other party, and my calculations of the comparison of household standards of living in accordance with Schedule II of the Guidelines:

            ☐     are attached.

            OR

            ☐    will be filed in accordance with the rules of the court upon receipt of the other party’s financial information.