ONTARIO

Court File Number

(Name of Court)
Form 13: Financial
at Statement (Support Claims)
Court office address sworn/affirmed

Applicant(s)
Full legal name & address for service street & number, municipality, Lawyers name & address street & number, municipality, postal code,
postal code, telephone & fax numbers and e-mail address (if any). telephone & fax numbers and e-mail address (if any).

Respondent(s)
Full legal name & address for service street & number, municipality, Lawyers name & address street & number, municipality, postal code,
postal code, telephone & fax numbers and e-mail address (if any). telephone & fax numbers and e-mail address (if any).

INSTRUCTIONS
1. YOU DO NOT NEED TO COMPLETE THIS FORM IF:
your only claim for support is for child support in the table amount specified under the Child Support
Guidelines and you are not making or responding to a claim described in paragraph 3 below.
2. USE THIS FORM IF:
you are making or responding to a claim for spousal support; or
you are responding to a claim for child support; or
you are making a claim for child support in an amount different from the table amount specified under the
Child Support Guidelines.
You must complete all parts of the form UNLESS you are ONLY responding to a claim for child support in the table
amount specified under the Child Support Guidelines AND you agree with the claim. In that case only complete
Parts 1, 2 and 3.
3. DO NOT USE THIS FORM AND INSTEAD USE FORM 13.1 IF:
you are making or responding to a claim for property or exclusive possession of the matrimonial home and
its contents; or
you are making or responding to a claim for property or exclusive possession of the matrimonial home and
its contents together with other claims for relief.

1. My name is (full legal name)

I live in (municipality & province)
and I swear/affirm that the following is true:
My financial statement set out on the following (specify number) pages is accurate to the
best of my knowledge and belief and sets out the financial situation as of (give date for which information is accurate)
for
Check one or me
more boxes, as the following person(s): (Give name(s) and relationship to you.)
circumstances
require.

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Form 13: Financial Statement (Support Claims) (page 2) Court file number
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NOTE: When you show monthly income and expenses, give the current actual amount if you know it or can find out. To get a monthly
figure you must multiply any weekly income by 4.33 or divide any yearly income by 12.

PART 1: INCOME
for the 12 months from (date) to (date)
Include all income and other money that you get from all sources, whether taxable or not. Show the gross amount here and show your
deductions in Part 3.
CATEGORY Monthly CATEGORY Monthly

1. Pay, wages, salary, including overtime 9. Rent, board received
(before deductions)
10. Canada Child Tax Benefit
2. Bonuses, fees, commissions 11. Support payments actually received
3. Social assistance 12. Income received by children
4. Employment insurance 13. G.S.T. refund
5. Workers compensation 14. Payments from trust funds
6. Pensions 15. Gifts received

7. Dividends 16. Other (Specify. If necessary, attach an
extra sheet.)
8. Interest
17. INCOME FROM ALL SOURCES

PART 2: OTHER BENEFITS

Show your non-cash benefits such as the use of a company car, a club membership or room and board that your employer or
someone else provides for you or benefits that are charged through or written off by your business.
Monthly Market
ITEM DETAILS
Value

18. TOTAL

19. GROSS MONTHLY INCOME AND BENEFITS (Add [17] plus [18].) $

PART 3: AUTOMATIC DEDUCTIONS FROM INCOME

for the 12 months from (date) to (date)

TYPE OF EXPENSE Monthly TYPE OF EXPENSE Monthly

20. Income tax deducted from pay 25. Group insurance

21. Canada Pension Plan 26. Other (Specify. If necessary, attach an
extra sheet.)
22. Other pension plans
23. Employment insurance
24. Union or association dues 27. TOTAL AUTOMATIC DEDUCTIONS

28. NET MONTHLY INCOME (Do the subtraction: [19] minus [27].) $

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Form 13: Financial Statement (Support Claims) (page 3) Court file number
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PART 4: TOTAL EXPENSES

for the 12 months from (date) to (date)
NOTE: If you need to complete this Part (see instructions on page 1), you must set out your TOTAL living expenses, including those
expenses involving any children now living in your home. This part may also be used for a proposed budget. To prepare a proposed
budget, photocopy Part 4, complete as necessary, change the title to Proposed Budget and attach it to this form.
TYPE OF EXPENSE Monthly TYPE OF EXPENSE Monthly
Housing Child(ren)
29. Rent/mortgage 57. School activities (field trips, etc.)
30. Property taxes & municipal levies 58. School lunches
31. Condominium fees & common expenses 59. School fees, books, tuition, etc. (for children)
32. Water 60. Summer camp
33. Electricity & heating fuel 61. Activities (music lessons, clubs, sports)
34. Telephone 62. Allowances
35. Cable television & pay television 63. Baby sitting
36. Home insurance 64. Day care
37. Home repairs, maintenance, 65. Regular dental care

gardening 66. Orthodontics or special dental care
Sub-total of items [29] to [37] 67. Medicine & drugs
Food, Clothing and Transportation etc. 68. Eye glasses or contact lenses
38. Groceries Sub-total of items [57] to [68]
39. Meals outside home Miscellaneous and Other
40. General household supplies 69. Books for home use, newspapers, magazines,

41. Hairdresser, barber & toiletries videos, compact discs
42. Laundry & dry cleaning 70. Gifts
43. Clothing 71. Charities
44. Public transit 72. Alcohol & tobacco
45. Taxis 73. Pet expenses
46. Car insurance 74. School fees, books, tuition, etc.
47. Licence 75. Entertainment & recreation
48. Car loan payments 76. Vacation
49. Car maintenance and repairs 77. Credit cards (but not for expenses mentioned

50. Gasoline & oil elsewhere in the statement)
51. Parking 78. R.R.S.P. or other savings plans
Sub-total of items [38] to [51] 79. Support actually being paid in any other case

Health and Medical (do not include child(ren)s
expenses) 80. Income tax and Canada Pension Plan (not

52. Regular dental care deducted from pay)
53. Orthodontics or special dental care 81. Other (Specify. If necessary attach an extra

54. Medicine & drugs sheet.)
55. Eye glasses or contact lenses Sub-total of items [69] to [81]
56. Life or term insurance premiums
Sub-total of items [52] to [56] 82. Total of items [29] to [81]

SUMMARY OF INCOME AND EXPENSES

Net monthly income (item [28] above) =$
Subtract actual monthly expenses (item [82] above) =$
ACTUAL MONTHLY SURPLUS/DEFICIT =$

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Form 13: Financial Statement (Support Claims) (page 4) Court file number
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PART 5: OTHER INCOME INFORMATION

1. I am employed by (name and address of employer)

self-employed, carrying on business under the name of (name and address of business)

unemployed since (date when last employed)

2. I attach the following required information (if you are filing this statement to update or correct an earlier statement, then you
do not need to attach income tax returns that have already been filed with the court.):
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 Canada Revenue Agency for those years; or
a statement from the Canada Revenue Agency that I have not filed any income tax returns from the
past 3 years; or
a direction in Form 13A signed by me to the Taxation Branch of the Canada Revenue Agency for the
disclosure of my tax returns and notices of assessment to the other party for the past 3 years.
I attach proof of my current income, including my most recent
pay cheque stub. employment insurance stub. workers compensation stub.
pension stub. other. (Specify.)
3. (check if applicable) I am an Indian within the meaning of the Indian Act (Canada) and all my income is tax
exempt and I am not required to file an income tax return. I have therefore not attached an income tax
return for the past three years.

PART 6: OTHER INCOME EARNERS IN THE HOME

Complete this part only if you are making or responding to a claim for undue hardship or spousal support. Indicate at paragraph 1 or
2, whether you are living with another person (for example, spouse, roommate or tenant). If you complete paragraph 2, also complete
paragraphs 3 to 6.

1. I live alone.
2. I am living with (full legal name of person)
3. This person has (give number) child(ren) living in the home.
4. This person works at (place of work or business)
does not work outside the home.
5. This person earns (give amount) $ per
does not earn anything.
6. This person contributes about $ per towards the household expenses.
contributes no money to the household expenses.

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Form 13: Financial Statement (Support Claims) (page 5) Court file number
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PART 7: PROPERTY
LAND
Kind of Property Address of Property Type of Ownership (Give your Estimated Market Value of Your
percentage of interest) Interest

83. TOTAL VALUE

GENERAL ITEMS AND VEHICLES (including household goods and furniture, jewellery, cars, boats, tools, sports and
hobby equipment)
Description (including where located, year and make) Estimated Market Value (not
replacement cost)

84. TOTAL VALUE

BANK ACCOUNTS, SAVINGS, SECURITIES AND PENSIONS (including R.R.S.P.s other savings plans, cash,
accounts in financial institutions, stocks, bonds, term deposits and controlling interest in an incorporated business)
Item/Type Institution (include location)/ Account Number Date of Maturity Amount/Estimated Market
Description (including issuer and date) Value

85. TOTAL VALUE

LIFE AND DISABILITY INSURANCE (List all policies now in existence.)
Company, Type & Policy No. Beneficiary Face Amount Todays Cash Surrender Value

86. TOTAL VALUE

BUSINESS INTERESTS (Show any interest in an unincorporated business owned today.)
Name of Firm or Company Nature and Location of Business Interest Estimated Market Value of Your
Interest

87. TOTAL VALUE

MONEY OWED TO YOU (including any court judgments in your favour, any estate money and any income tax refunds
owed to you.)
Details (including name of debtors) Amount Owed to You

88. TOTAL OF MONEY OWED TO YOU

OTHER PROPERTY
Type of Property Description and Location Estimated Market Value

89. TOTAL VALUE OF OTHER PROPERTY

90. TOTAL VALUE OF ALL PROPRETY

(Add items [83] to [89].)

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Form 13: Financial Statement (Support Claims) (page 6) Court file number
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PART 8: DEBTS AND OTHER LIABILITIES

Debts and other liabilities may include any money owed to the Canada Revenue Agency, contingent liabilities such as guarantees or
warranties given by you (but indicated that they are contingent), any unpaid legal or professional bills as a result of this case,
mortgages, charges, liens, notes, credit cards and accounts payable.

Full Amount Now

Type of Debt Creditor Details Monthly Payments
Owing
Bank, trust or finance company, or
credit union loans
Amounts owed to credit card
companies
Other debts
91. TOTAL OF DEBTS AND OTHER LIABILITIES:

PART 9: SUMMARY OF ASSETS AND LIABILITIES

Amounts
TOTAL ASSETS (from item [90] above) $
Subtract TOTAL DEBTS (from item [91] above) $
92. NET WORTH $

I do not expect changes in my financial situation.

I do expect changes in my financial situation as follows:

I attach a proposed budget in the format of Part 4 of this form.

NOTE: As soon as you find out that the information in this financial statement is incorrect or incomplete, or there is a
material change in your circumstances that affects or will affect the information in this financial statement, you MUST serve
on every other party to this case and file with the court:
a new financial statement with updated information, or
if changes are minor, an affidavit in Form 14A setting out the details of these changes.

Sworn/Affirmed before me at
municipality
in
province, state or country Signature
(This form is to be signed in front of a
on lawyer, justice of the peace, notary public
date Commissioner for taking affidavits or commissioner for taking affidavits.)
(Type or print name below if signature is
illegible.)

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