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

For persons to which the 2009 amendments apply

PDF version

Form 65

22 KB, 1 page

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

(Title Form 1)

Check box if this is an original Original Checkbox for amended Amended

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

Income and Expenses
Monthly IncomeBankrupt/
Debtor		Other members of the family unitTotal
Net employment incomeSpace to insert net employment income of bankrupt/debtorempty cellempty cell
Net pension/annuitiesSpace to insert net pension/annuities of bankrupt/debtorempty cellempty cell
Net child supportSpace to insert net child support of bankrupt/debtorempty cellempty cell
Net spousal support Space to insert net spousal support of bankrupt/debtorempty cellempty cell
Net employment insurance benefitsSpace to insert net employment insurance benefits of bankrupt/debtorempty cellempty cell
Net social assistance Space to insert net social insurance of bankrupt/debtorempty cellempty cell
Self-employment income empty cellempty cell
Gross Space to insert gross self-employment incomeNetSpace to insert net self-employment incomeempty cell empty cell 
Other net income
(Such as amounts received as damages for wrongful dismissal, as pay equity settlement, or that relate to workers' compensation)
( details Space to insert details of other net income)		 Space to insert other net incomeempty cell empty cell 
Total Monthly Income$Space to insert total monthly income amount of bankrupt/debtor(1)$Space to insert total monthly income amount of other members of the family unit(2)Footnote aempty cell 
Total Monthly Income of the Family Unit ((1) + (2))empty cell empty cell $Space to insert total monthly income of the family unit ((1)+(2))(3)
Monthly Non-Discretionary Expenses
Child support paymentsSpace to insert child support payments of bankrupt/debtorempty cellempty cell
Spousal support paymentsSpace to insert spousal support payments of bankrupt/debtorempty cellempty cell
Child careSpace to insert child care of bankrupt/debtorempty cellempty cell
Health condition expensesSpace to insert health condition expenses of bankrupt/debtorempty cellempty cell
Fines/penalties imposed by the CourtSpace to insert fines/penalties imposed by the Court of bankrupt/debtorempty cellempty cell
Expenses as a condition of employmentSpace to insert expenses as a condition of employment of bankrupt/debtorempty cellempty cell
Debts where stay has been lifted Space to insert debts where stay has been lifted of bankrupt/debtorempty cellempty cell

Other expenses
( details Space to insert details of other expenses)

Space to insert other expenses of bankrupt/debtorempty cellempty cell
Total Monthly Non-Discretionary Expenses$Space to insert total monthly non-discretionary expenses of bankrupt/debtor (4)$Space to insert total monthly non-discretionary expenses of other members of the family unit (5)empty cell
Total Monthly Non-Discretionary Expenses of the Family Unit ((4) + (5))empty cellempty cell$Space to insert total monthly non-discretionary expenses of the family unit ((4)+(5)) total(6)
Available Monthly Income of the Bankrupt/Debtor ((1) - (4)) $Space to insert amount for available monthly income of the bankrupt/debtor ((1)-(4)) (7)empty cellempty cell
Available Monthly Income of the Family Unit ((3) - (6))empty cellempty cell$Space to insert total amount for available monthly income of the family unit ((3)-(6))(8)
Bankrupt's/Debtor's Portion of the Available Monthly Income of the Family Unit ((7) / (8) X 100)empty cell empty cell % Space to insert total percentage of the bankupt/debtorès portion of available income of the family unit ((7)/(8)x100)(9)
Monthly discretionary expenses: (Family unit)
Housing expensesRent/mortgage/hypothecSpace to insert rent/mortgage/hypothec expenses
Property taxes/condo feesSpace to insert property taxes/condo fees
Heating/gas/oilSpace to insert heating/gas/oil expenses
TelephoneSpace to insert telephone expenses
CableSpace to insert cable expenses
HydroSpace to insert hydro expenses
WaterSpace to insert water expenses
FurnitureSpace to insert furniture expenses
OtherSpace to insert other housing expenses
Personal expensesSmokingSpace to insert smoking expenses
AlcoholSpace to insert alcohol expenses
Dining/lunches/restaurantsSpace to insert dining/lunches/restaurants expenses
Entertainment/sportsSpace to insert entertainment/sports expenses
Gifts/charitable donationsSpace to insert gifts/charitable donations
Allowances Space to insert allowances expenses
OtherSpace to insert other personal expenses
Non-recoverable medical expensesPrescriptionsSpace to insert prescriptions expenses
DentalSpace to insert dental expenses
OtherSpace to insert other non-recoverable medical expenses
Living expensesFood/grocerySpace to insert food/grocery expenses
Laundry/dry cleaningSpace to insert laundry/dry cleaning expenses
Grooming/toiletriesSpace to insert grooming/toiletries expenses
ClothingSpace to insert clothing expenses
OtherSpace to insert other living expenses
Transportation expenses Car lease/paymentsSpace to insert car lease/payments
Repair/maintenance/gasSpace to insert repair/maintenance/gas expenses
Public transportationSpace to insert public transportation expenses
OtherSpace to insert other transportation expenses
Insurance expensesVehicleSpace to insert vehicle insurance expenses
HouseSpace to insert house insurance expenses
Furniture/contents Space to insert furniture/contents insurance expenses
Life insuranceSpace to insert life insurance expenses
OtherSpace to insert other insurance expenses
PaymentsTo the estateSpace to insert payments to the estate
To secured creditorSpace to insert payments to secured creditor
(Other than mortgage and vehicle)Space to insert payments other than mortgage and vehicle
OtherSpace to insert other payments
Total Monthly Discretionary Expenses (Family Unit)- $Space to insert amount for total monthly discretionary expenses (family unit)(10)
Monthly Surplus or (Deficit) Family Unit ((8) - (10)) =$Space to insert amount for monthly surplus or (deficit) family unit ((8)-(10))(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 number
empty cell 
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
( details) Space to insert details
Space to insert amount bankrupt has agreed to pay monthly to repurchase assets (13)
Residual amount paid into the estate ((12) - (13))
Space to insert residual amount paid into the estate (14)

Payments required by Directive No. 11R2 (Surplus Income)

Monthly amount required by Directive No. 11R2 (Surplus Income) based on percentage established on line (9)
Space to insert monthly amount required by Directive No. 11R2 (15)
Difference between (14) and (15)
Space to insert difference between (14) and (15) (16)
Other applicable comments (If amount on line (14) is less than amount on line (15),
explain why the required payments are not being made: Space to insert other applicable comments)

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

empty cell 

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

Space to insert signature of trustee
Licensed Insolvency Trustee
Space to insert signature of bankrupt/debtor
Bankrupt/Debtor

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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