Government of Ontario: Ministry of Community and Social Services

Family Responsibility Office
Downsview ON M3M 3A3

Request for Director’s Statement of Arrears
(Statement of Account)

(Pursuant to Ontario Regulation 160/00 made under the Family Responsibility and Support Arrears Enforcement Act, 1996)

If you wish to receive a Director’s Statement of Arrears (statement of account), please attach a cheque or money order for $25.00 to this form or fill out the credit card section.
Make the cheque or money order payable to Family Responsibility Office.
Mail payment and form to address below:

Family Responsibility Office
PO Box 622

Steeles West Post Office
Toronto ON M3J 0K8

Please do not send regular support payments to this address.

SECTION A

Please print your name

I am the Support Recipient
Support Payor
Solicitor for Support Recipient
Solicitor for Support Payor
Assignee

Case Number

Telephone Number

Address

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

Support Payor’s Name
Support Recipient’s Name
Client Signature

SECTION B

$25.00 payment method Cheque/Money Order (attached) or Visa MasterCard

Credit Card Number
Credit Card Expiry Date (MM/YY)
Name of Cardholder
Authorized Signature

Date

For urgent requests, please fax this completed form to 416 240-2468.

Medium Sensitivity when completed