Government of Ontario: Ministry of Community and Social Services

Family Responsibility Office
P.O. Box 220
Downsview ON M3M 3A3

FINANCIAL STATEMENT

Family Responsibility and Support Arrears Enforcement Act, 1996

Form 4

Case Number

You have 15 days to complete this form and return it to the Family Responsibility Office

I, (Name of Payor) , of

Address Street Name and Number
Municipality
Province Postal Code

solemnly declare that all details of my financial situation are accurately set out below.

Part 1 - Employment Information

Occupation: What type of work do you do?

Are you self-employed? Yes No
If yes, financial statements for the past two years must be attached.

Are you now employed Full-time Part-time Unemployed

Current employer: (if more than one employer, provide details of other employers on a separate sheet)

Name

Address: Street Name and Number
Municipality
Province Postal Code

How long have you worked for this employer?

When are you paid? (check one) once a month
twice a month
once every two weeks
weekly
other (specify)

If paid by commission, give details of the arrangement for payment that you have with your employer. Please tell us if you receive advances, how such advances are calculated, and if you are required to reimburse your employer should you fail to earn the commission or meet any production target.

If paid by commission, are the terms of the arrangement
between you and your employer in writing? Yes
No
If yes, attach a copy of the document.
If no, when was the current arrangement reached?
(date)
When will you next discuss changing the commission arrangements with your employer?
(date)

Last employer: (Complete only if not working now) Name

Address: Street Name and Number
Municipality
Province Postal Code

How long did you work for this employer? From To

Reason employment ended (specify)

IMPORTANT: PLEASE FILL IN EITHER THE WEEKLY OR MONTHLY INCOME COLUMN, NOT BOTH.

If you receive or pay some money once a month, but are using the column for weekly income, divide the monthly amount by 4.33 to get the amount per week. If you receive or pay some money every week, but are using the column for monthly income, multiply the weekly amount by 4.33 to get the amount per month.

Part 2 - Income Information

**Income - A**
Source of Income	Weekly $	Monthly $
Pay, Wages, Salary (before deductions)
Bonuses	Bonuses Weekly $	Bonuses Monthly $
Public Assistance	Public Assistance Weekly $	Public Assistance Monthly $
Employment Insurance	Employment Insurance Weekly $	Employment Insurance Monthly $
Workers' Compensation Payments	workers' compensation Weekly $	workers' compensation Monthly $
Pensions	Pensions Weekly $	Pensions Monthly $
Rent, board you collect from others
Dividends	Dividends Weekly $	Dividends Monthly $
Interest	Interest Weekly $	Interest Monthly $
Commissions	Commissions Weekly $	Commissions Monthly $
Support from others	Support from others Weekly $	Support from others Monthly $
Family Allowance	Family Allowance Weekly $	Family Allowance Monthly $
Other (specify)	Other Weekly $	Other Monthly $
Total Income $ (A)	$	$

**Income Deductions - B**
Type of Deduction	Weekly $	Monthly $
Income Tax	Income Tax Weekly $	Income Tax Monthly $
Canada Pension Plan	Canada Pension Plan Weekly $	Canada Pension Plan Monthly $
Employment Insurance	Employment Insurance Weekly $	Employment Insurance Monthly $
Pension Plan Contributions	Pension Plan Contributions Weekly $	Pension Plan Contributions Monthly $
Union or other dues	Union or other dues Weekly $	Union or other dues Monthly $
Group Insurance	Group Insurance Weekly $	Group Insurance Monthly $
Credit Union Loan	Credit Union Loan Weekly $	Credit Union Loan Monthly $
Credit Union Savings	Credit Union Savings Weekly $	Credit Union Savings Monthly $
Other (specify, i.e. charity)	Other Weekly $	Other Monthly $
Total Deductions $ (B)	$	$

Take Home Income (A) - (B) = $

Part 3 - Expenses Information

**Expenses - C**
Expenses - C	Weekly $	Monthly $
Groceries and Household Supplies
Meals outside home	Meals outside home Weekly $	Meals outside home Monthly $
Clothing	Clothing Weekly $	Clothing Monthly $
Laundry and Dry Cleaning		Laundry and dry cleaning Monthly $
Rent or Mortgage	Rent or mortgage Weekly $	Rent or mortgage Monthly $
Taxes	Taxes Weekly $	Taxes Monthly $
Home Insurance	Home insurance Weekly $	Home insurance Monthly $
Heating Fuel	Heating fuel Weekly $	Heating fuel Monthly $
Water	Water Weekly $	Water Monthly $
Hydro	Hydro Weekly $	Hydro Monthly $
Telephone	Telephone Weekly $	Telephone Monthly $
Cable TV	Cable TV Weekly $	Cable TV Monthly $
Repairs and Maintenance	Repairs and maintenance Weekly $	Repairs and maintenance Monthly $
Other	Other Weekly $	Other Monthly $
Health and Medical Insurance	Health and Medical Insurance Weekly $	Health and Medical Insurance Monthly $
Drugs	Drugs Weekly $	Drugs Monthly $
Dental Care	Dental Care Weekly $	Dental Care Monthly $
Sub-total (C)	$	$

**Expenses - D**
Expenses - D	Weekly $	Monthly $
Public Transit, Taxis, etc.	Public transit, taxis, etc. Weekly $	Public transit, taxis, etc. Monthly $
Vehicle operation, gas and oil
Vehicle Insurance and Licence	Vehicle insurance and licence Weekly $
Maintenance	Maintenance Weekly $	Maintenance Monthly $
Life Insurance	Life insurance Weekly $	Life insurance Monthly $
School Fees, Books, etc.	School fees, books, etc. Weekly $	School fees, books, etc. Monthly $
Music Lessons, Sports Fees, etc.
Newspapers, Publications, Stationery
Entertainment, Recreation	Entertainment, recreation Weekly $	Entertainment, recreation Monthly $
Alcohol, Tobacco	Alcohol, tobacco Weekly $	Alcohol, tobacco Monthly $
Vacation	Vacation Weekly $	Vacation Monthly $
Hairdresser, Barber	Hairdresses, barber Weekly $	Hairdresses, barber Monthly $
Toilet Articles (hairspray, soap, etc.)
Babysitting, Daycare	Babysitting, daycare Weekly $	Babysitting, daycare Monthly $
Children's Allowances, Gifts	Children's allowances, gifts Weekly $	Children's allowances, gifts Monthly $
Support Payments (actually being paid)
Savings for future (excluding payroll deductions)
Other (specify)	Other Weekly $	Other Monthly $
Sub-total (D)	$	$

Total Expenses (Excluding Debt Payments) Add (C) + (D) = $

Part 4 - Debt Information

If you own a car, are payments still owing? Yes No

If yes, Name of lender

Address

Date of Purchase
Initial amount financed? $
Balance Owing $
Monthly payments $

**Other Debts**
*if space not sufficient, use separate sheet*
Type of Debt	Creditor (Name and Address)	Security	Full Amount Now Owing	Monthly Payments	Are Payments Currently Being Met (Yes/No)
Bank or Trust Company Loans	Bank or Trust Company Loans - Creditor	Bank or Trust Company Loans - Security			Yes No
Bank or Trust Company Loans	Bank or Trust Company Loans - Creditor	Bank or Trust Company Loans - Security			Yes No
Bank or Trust Company Loans	Bank or Trust Company Loans - Creditor	Bank or Trust Company Loans - Security			Yes No
Bank or Trust Company Loans	Bank or Trust Company Loans - Creditor	Bank or Trust Company Loans - Security			Yes No
Finance Company Loans		Finance Company Loans - Security			Yes No
Finance Company Loans	Bank or Trust Company Loans - Creditor	Finance Company Loans - Security			Yes No
Finance Company Loans	Bank or Trust Company Loans - Creditor	Finance Company Loans - Security			Yes No
Finance Company Loans	Bank or Trust Company Loans - Creditor	Finance Company Loans - Security			Yes No
Credit Card Loans	Credit Card Loans - Creditor	Credit Card Loans - Security		Credit Card Loans - Monthly Payments	Yes No
Credit Card Loans	Credit Card Loans - Creditor	Credit Card Loans - Security		Credit Card Loans - Monthly Payments	Yes No
Credit Card Loans	Credit Card Loans - Creditor	Credit Card Loans - Security		Credit Card Loans - Monthly Payments	Yes No
Credit Card Loans	Credit Card Loans - Creditor	Credit Card Loans - Security		Credit Card Loans - Monthly Payments	Yes No
Other Debts	Other Debts - Creditor	Other Debts - Security	Other Debts - Full Amount Now Owing	Other Debts - Monthly Payments	Yes No
Other Debts	Other Debts - Creditor	Other Debts - Security	Other Debts - Full Amount Now Owing	Other Debts - Monthly Payments	Yes No
Other Debts	Other Debts - Creditor	Other Debts - Security	Other Debts - Full Amount Now Owing	Other Debts - Monthly Payments	Yes No
Other Debts	Other Debts - Creditor	Other Debts - Security	Other Debts - Full Amount Now Owing	Other Debts - Monthly Payments	Yes No
TOTALS			TOTAL Full Amount Now Owing	TOTAL Monthly Payments

Part 5 - Assets Information


Type	Details (If space is not sufficient, use separate sheet) State Address of Property and Nature of Ownership	Value or Amount
Real Estate	1.	1. $
Real Estate	2.	2. $
Real Estate	3.	3. $


Type	Details (If space is not sufficient use separate sheet) Year and Make	Value or Amount
Cars, Boats, Vehicles	1.	1. $
Cars, Boats, Vehicles	2.	2. $
Cars, Boats, Vehicles	3.	3. $


Type	Details (If space is not sufficient use separate sheet) Address Where Located	Value or Amount
Household Goods and Furniture	1.	1. $
Household Goods and Furniture	2.	2. $
Household Goods and Furniture	3.	3. $


Type	Details (If space is not sufficient use separate sheet) Description and Address Where Located	Value or Amount
Tools, Sports, Hobby Equipment	1.	1. $
Tools, Sports, Hobby Equipment	2.	2. $
Tools, Sports, Hobby Equipment	3.	3. $


Type	Details (If space is not sufficient use separate sheet) Type - Issuer - Due Date - Number of Shares	Value or Amount
Bonds - Shares Term Deposits Investment Certificates	1.	1. $
Bonds - Shares Term Deposits Investment Certificates	2.	2. $
Bonds - Shares Term Deposits Investment Certificates	3.	3. $


Type	Details (If space is not sufficient use separate sheet) Name and Address of Institution Account Number	Value or Amount
Bank Accounts	1.	1. $
Bank Accounts	2.	2. $
Bank Accounts	3.	3. $


Type	Details (If space is not sufficient use separate sheet) Type and Issuer Account Number	Value or Amount
Savings Plans R.R.S.P Pension Plans	1.	1. $
Savings Plans R.R.S.P Pension Plans	2.	2. $
Savings Plans R.R.S.P Pension Plans	3.	3. $


Type	Details (If space is not sufficient, use separate sheet) Type - Beneficiary - Face Amount	Cash Surrender Value
Life Insurance	1.	1. $
Life Insurance	2.	2. $
Life Insurance	3.	3. $


Type	Details (If space is not sufficient, use separate sheet) Name and Address of Business	Cash Surrender Value
Interest in Business (Attach separate financial statement for each business)	1.	1. $
Interest in Business (Attach separate financial statement for each business)	2.	2. $
Interest in Business (Attach separate financial statement for each business)	3.	3. $


Type	Details (If space is not sufficient, use separate sheet) Name and Address of Debtors	Cash Surrender Value
Money Owed to You	1.	1. $
Money Owed to You	2.	2. $
Money Owed to You	3.	3. $


Type	Details (If space is not sufficient, use separate sheet) Description and Address of Location	Cash Surrender Value
Other Assets	1.	1. $
Other Assets	2.	2. $
Other Assets	3.	3. $

Total Estimated Value $ of all assets listed above

Part 6 - Information

1. The expenses shown on Part 3 of this form are for: Me alone

Me and the following other persons: (Give name(s) and relationship(s))

2. I understand that I am required to attach proof of my income to this form.

I attach to this statement proof of my current income,
including my three most recent
paycheque stubs
employment insurance benefits
workers' compensation payments
pension payments
other (specify)

Note:
If you do not receive pay stubs or payment statements from an income source, attach a letter from the income source stating the amount of money received for the three consecutive payments made to you immediately before the date of the financial statement;

AND
I attach to this form a copy of my income tax returns that were filed with the Canada Revenue Agency for the past 3 taxation years, together with a copy of all material filed with the returns and a copy of any notices of assessment or re-assessment that I have received from the Agency for these years.

I attach to this form a statement from the Canada Revenue Agency that I have not filed any income tax returns for the past 3 years.

I am unable to attach my past 3 years' income tax returns and notices of assessment. I am attaching Canada Revenue Agency statements of my income and deductions for the past 3 years as proof of my income.

Sworn before me at the in the of on 20.
A Commissioner, etc.

Signature

(This form is to be signed before a lawyer, justice of the peace, notary public or commissioner for taking affidavits.)

AFTER REVIEWING THIS STATEMENT, THE DIRECTOR MAY REQUIRE OTHER EVIDENCE VERIFYING YOUR INCOME.

THE LAW REQUIRES THAT YOU MUST COMPLETE AND DELIVER THE COMPLETED FINANCIAL STATEMENT TO THE FAMILY RESPONSIBILITY OFFICE WITHIN 15 DAYS OF BEING SERVED WITH THE REQUEST TO COMPLETE IT.

IF, AFTER PROVIDING THE DIRECTOR WITH A COMPLETED FINANCIAL STATEMENT, YOU DISCOVER THAT SOME OF THE INFORMATION YOU PROVIDED WAS INCOMPLETE OR WRONG, THE LAW REQUIRES THAT YOU PROVIDE THE DIRECTOR WITH A CORRECT FINANCIAL STATEMENT WITHIN 10 DAYS OF THE DISCOVERY OF THE ERROR(S).

IF YOU FAIL TO COMPLY, YOU MAY BE ORDERED BY THE COURT TO COMPLY AND THE COURT MAY ORDER THAT A WARRANT FOR YOUR ARREST BE ISSUED.

IT IS AN OFFENCE TO KNOWINGLY FAIL TO COMPLY WITH THESE REQUIREMENTS. A PERSON CONVICTED OF AN OFFENCE IS LIABLE TO A FINE OF UP TO $10,000.

FRO-010E (June 15, 2005)

Version française disponible