Form 65—Monthly Income and Expense Statement of the Bankrupt and the Family Unit and Information (or Amended Information) Concerning the Financial Situation of the Individual Bankrupt

For persons to which the 2009 amendments do not apply

PDF version

Form 65

22 KB, 2 pages

(Section 68 and Subsection 102(3) of the Act and Rule 105(4))

(Title Form 1)

The information concerning the monthly income and expense statement of the bankrupt and the family unit, the financial situation of the bankrupt and the bankrupt's obligation to make payments required under section 68 of the Act to the estate of the bankrupt are as follows:

monthly income
type of expense Bankrupt Other members of the family unit Total
Net employment income Space to insert net employment income
Net pension/Annuities Space to insert income from net pension/Annuities
Net child support Space to insert income from Net child support
Net spousal support Space to insert income from Net spousal support
Net employment insurance benefits Space to insert income from Net employment insurance benefits
Net social assistance Space to insert income from Net social assistance
Self-employment income - Net
Gross Space to insert gross Self-employment income		Space to insert net self-employment income
Other net income
(Provide details Space to insert income from )		Space to insert Other net income
total monthly income $Space to insert Total Monthly Income (1) (1) $Space to insert Total Monthly Income (2) (2)Footnote **
total monthly income of the family unit ((1) + (2)) arrow$Space to insert Total Monthly Income of the Family Unit(3)
monthly non-discretionary expenses
type of expense Bankrupt Other members of the family unit Total
Child support payments Space to insert Child support payments
Spousal support payments Space to insert Spousal support payments
Child care Space to insert expenses from Child care
Health condition expenses Space to insert Health condition expenses
Fines/Penalties imposed by the court Space to insert expenses from Fines/Penalties imposed by the court
Expenses as a condition of employment Space to insert expenses as a condition of employment
Debts where stay has been lifted Space to insert Debts where stay has been lifted
Other expenses
(Provide details Space to insert details of other expenses)		 Space to insert other expenses
total monthly non-discretionary expenses $Space to insert Total Monthly non-Discretionary Expenses (4)(4) $Space to insert total monthly non-discretionary expenses (5)(5)
Total Monthly non-Discretionary Expenses of the Family Unit ((4) + (5)) arrow$Space to insert total monthly non-discretionary expenses of the family unit ((4) + (5))(6)
Available Monthly Income of the Bankrupt ((1) - (4)). $Space to insert Available Monthly Income of the Bankrupt ((1) - (4)) (7)
Available Monthly Income of the Family Unit ((3) - (6)) arrow$Space to insert Available Monthly Income of the Family Unit ((3) - (6))(8)
Bankrupt's Portion of the Available Monthly Family Unit Income ((7) / (8) X 100)) arrow%Space to insert Bankrupt's Portion of the Available Monthly Family Unit Income ((7) / (8) X 100))(9)
monthly discretionary expenses: (Family unit)
Housing expenses Living expenses
Rent/Mortgage/Hypothec Space to insert expenses for Rent/Mortgage/Hypothec Food/Grocery Space to insert expenses for Food/Grocery
Property taxes/Condo fees Space to insert expenses for Property taxes/Condo fees Laundry/Dry cleaning Space to insert expenses for Laundry/Dry cleaning
Heating/Gas/Oil Space to insert expenses for Heating/Gas/Oil Grooming/Toiletries Space to insert expenses for Grooming/Toiletries
Telephone Space to insert expenses for Telephone Clothing Space to insert expenses for Clothing
Cable Space to insert expenses for Cable Other Space to insert other living expenses
Hydro Space to insert expenses for Hydro Transportation expenses
Water Space to insert expenses for Water Car lease/Payments Space to insert expenses for Car lease/Payments
Furniture Space to insert expenses for Furniture Repair/ Maintenance/Gas Space to insert expenses for Repair/ Maintenance/Gas
Other Space to insert other housing expenses Public transportation Space to insert expenses for Public transportation
Personal expenses Other Space to insert expenses for other transportation
Smoking Space to insert expenses for Smoking Insurance expenses
Alcohol Space to insert expenses for Alcohol Vehicle Space to insert expenses for Vehicle
Dining/Lunches/Restaurants Space to insert expenses for Dining/Lunches/Restaurants House Space to insert expenses for House
Entertainment/Sports Space to insert expenses for Entertainment/Sports Furniture/Contents Space to insert expenses for Furniture/Contents
Gifts/Charitable donations Space to insert expenses for Gifts/Charitable donations Life insurance Space to insert expenses for Life insurance
Allowances Space to insert expenses for Allowances Other Space to insert expenses for other Insurance expenses
Other Space to insert other personal expenses Payments
Non-recoverable medical expenses To the estate Space to insert payments to the estate
Prescriptions Space to insert expenses for Prescriptions To secured creditor Space to insert payments to secured creditor
Dental Space to insert dental expenses (Other than mortgage and vehicle) Space to insert payments (other than mortgage and vehicle)
Other Space to insert other non-recoverable medical expenses Other Space to insert other payments
total monthly discretionary expenses (family unit) - $Space to insert Total Monthly Discretionary Expenses (10)
monthly surplus or (deficit) family unit ((8) - (10)) = $Monthly Surplus or (Deficit) (11)

Information (or Amended Information) Concerning the Financial Situation of the Individual Bankrupt

Payments to the estate as per agreement

Number of persons in household family unit, including bankrupt: Space to insert income from number of persons in household family unit

Total amount bankrupt has agreed to pay monthly Space to insert Total amount bankrupt has agreed to pay monthly(12)

Amount bankrupt has agreed to pay monthly to repurchase assets Space to insert amount to repurchase assets(13)
(provide details) Space to insert income from details on amount to repurchase assets

Residual amount paid into the estate ((12) - (13)) Space to insert Residual amount paid into the estate(14)

Payments required by the Directive on Surplus Income

Monthly amount required by the Directive on Surplus Income based on percentage established on line (9) Space to insert monthly amount required on surplus income(15)

Difference between amounts at lines (14) and (15) Space to insert difference between amounts at lines (14) and (15)(16)

Other applicable comments: Space to insert other applicable comments
( If amount at line (14) is less than amount at line (15), explain why the required payments are not being made: Space to insert income from )

Amendment or material change: (If the information relates to a material change or an amendment, provide details: Space to insert amendment or material change)

Dated at Space to insert city , this Space to insert day of month day of Space to insert month Space to insert income year.

Space to insert trustee's signature
Trustee
Space to insert Bankrupt's Signature
Bankrupt

Notes :

In a joint assignment, only one form is required and each debtor's monthly income and non-discretionary expenses have to be explained in detail.

If a copy of this Form is sent electronically by means such as email, the name and contact information of the sender, prescribed in Form 1.1, must be added at the end of the document.

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