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

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

I, , of

Address

  

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

Part 1 - Employment Information



Are you self-employed?    
If yes, financial statements for the past two years must be attached.
Are you now employed      

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



Address:

  

When are you paid? (check one)



If paid by commission, are the terms of the arrangement
between you and your employer in writing?


If yes, attach a copy of the document.
If no, when was the current arrangement reached?

When will you next discuss changing the commission arrangements with your employer?

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

  
How long did you work for this employer?   

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
Public Assistance
Employment Insurance
Workers' Compensation Payments
Pensions
Rent, board you collect from others
Dividends
Interest
Commissions
Support from others
Family Allowance
Other
(A)

 

Income Deductions - B
Type of Deduction Weekly $ Monthly $
Income Tax
Canada Pension Plan
Employment Insurance
Pension Plan Contributions
Union or other dues
Group Insurance
Credit Union Loan
Credit Union Savings
Other
(B)

Part 3 - Expenses Information

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


Expenses - D
Expenses - D Weekly $ Monthly $
Public Transit, Taxis, etc.
Vehicle operation, gas and oil
Vehicle Insurance and Licence
Maintenance
Life Insurance
School Fees, Books, etc.
Music Lessons, Sports Fees, etc.
Newspapers, Publications, Stationery
Entertainment, Recreation
Alcohol, Tobacco
Vacation
Hairdresser, Barber
Toilet Articles (hairspray, soap, etc.)
Babysitting, Daycare
Children's Allowances, Gifts
Support Payments (actually being paid)
Savings for future (excluding payroll deductions)
Other
(D)

Part 4 - Debt Information

If you own a car, are payments still owing?   
If yes,






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
Bank or Trust Company Loans
Bank or Trust Company Loans
Finance Company Loans
Finance Company Loans
Finance Company Loans
Finance Company Loans
Credit Card Loans
Credit Card Loans
Credit Card Loans
Credit Card Loans
Other Debts
Other Debts
Other Debts
Other Debts
TOTALS

 

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. $

 

Part 6 - Information

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

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

  1. I attach to this statement proof of my current income,
    including my three most recent





    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






 

.

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

© Queen's Printer for Ontario, 2005