Consolidated Statutes and Regulations
Consolidated Statutes
Consolidated Regulations
Annual Statutes and Regulations
Annual Statutes
Annual Regulations
Additional information
Québec Official Publisher
What’s new?
Information note
Policy of the Minister of Justice
Laws: Amendments
Laws: Provisions not in force
Laws: Provisions brought into force
Annual Statutes: PDF versions since 1996
Regulations: Amendments
Annual Regulations: PDF versions since 1996
Court Decisions
C-25.01, r. 6 - Rules of practice of the Superior Court of Québec in family matters
Schedule
Disposition versions
FORM III
CANADA
PROVINCE OF QUÉBEC SUPERIOR COURT
DISTRICT OF Family Division
NO. __________ ________________________________________
________________________________________
Party: ___________________________________
vs.
________________________________________
Party: ___________________________________
STATEMENT OF INCOME AND EXPENDITURES AND BALANCE SHEET
I, the undersigned, ______________________________, domiciled at ______________________________ in the district of ______________________________, do hereby declare under oath that:
□ I acknowledge my ability to pay the amounts claimed but deny that the other party is entitled to receive them (Rule 28).
□ I receive only income security benefits in the amount of $__________ per month.
(1) I am the ______________________________ (plaintiff or defendant) in this case.
(2) I have enclosed with this sworn declaration a copy of my federal and provincial income tax returns, along with notices of assessment for the years __________.
(3) All the details pertaining to my financial situation are accurately disclosed hereunder and are true to my personal knowledge.
INCOME FOR THE CURRENT YEAR
Category Per week Par month Par year
Gross salary
Commissions/tips
Net income form business or
self-employment (attach financial
statement)
Employment insurance
Support paid by a third party
Retirement or disability
pension, or other pension
Interest and dividends
Net rentals (attach a statement of
income and expenses for each property)
Other (Please specify)
TOTAL a)
Total per week $__________ x 4.33 = b)$__________
per month
Total per year $__________ ÷ 12 = c)$__________
per month
TOTAL MONTHLY INCOME: (a + b + c) = $__________
EXPENSES ON A MONTHLY BASIS
(To calculate the exact monthly amount, multiply a weekly expenses by 4.33 and divide an annual expense by 12.)
Category Per month
1 Contributions to the Régime des rentes du
Québec and the Canada Pension Plan
2 Employment insurance premiums
3 Contributions to a retirement plan
4 Group insurance premiums
5 Union dues and professional association fees
6 Rent/mortgage
7 Common charges (co-ownership)
8 Municipal, school and water taxes
9 Premiums for insurance on dwelling
10 Insurance: life, accident, invalidity
11 Electricity
12 Heating
13 Telephone
14 Cable T.V.
15 Repairs to and upkeep of main residence
16 Housekeeping
17 Purchase of furniture, appliances and bedding
18 Repairs to furniture and appliances
19 Food
20 Restaurant meals: – For work
– For leisure
21 Medicines and toilet articles
22 Diapers and baby formula
23 Dental care
24 Eye glasses, contact lenses and products for their upkeep
25 Clothing
26 Laundry and dry-cleaning
27 Hairdresser and beauty care
28 Taxis and public transport
29 Vehicle – Payments/rental
– Insurance
– Licence and registration
– Gas
– Repairs
– Parking
30 Education costs (tuition, books, supplies, meals, outings,
extra-curricular activities, uniform)
31 Registered education savings plan
32 Child day care costs (day care, babysitter, day camp)
– For work
– For leisure
33 Outings and entertainment
34 Sports activities
35 Equipment: sports, leisure activities, etc.
36 Courses/lessons
37 Toys, gifts
38 Books, magazines, newspapers, records and cassettes
39 Pets
40 Tobacco and alcohol
41 Vacations
42 Camp
43 Children’s allowance
44 Savings – retirement savings
45 Payment of debts 1)
2)
3)
46 Lawyer’s fees
47 Secondary residence (enclose details on separate sheet)
48 Other:
Anticipated expenditures:
TOTAL MONTHLY EXPENDITURES
SUMMARY
Total monthly income (see page 1) $__________
(less) -
Income tax (before support)* $__________
NET INCOME $__________
$
(less) -
Total monthly expenditures $__________
SURPLUS/(DEFICIT) $__________
SUPPORT AND FINANCIAL IMPACT
INFORMATION TO BE SUPPLIED BY THE PARTY CLAIMING SUPPORT
Net contribution required of Alimentary debtor $__________
plus +
Income tax on the support claimed and Tax credits lost* $__________
GROSS SUPPORT CLAIMED $__________
INFORMATION TO BE SUPPLIED BY THE PARTY FROM WHOM SUPPORT IS CLAIMEND
GROSS SUPPORT OFFERED $__________
(less) -
Income tax savings and tax credits recovered as
result of support offered* $__________
Net cost of support offered $__________
* Indicate source of calculation ________________________________________________
NAME AND ADDRESS OF EMPLOYER
ASSETS
Indicate cash, accounts in banks or other financial institutions and the market
value of assets by category (disregarding any related debts): real estate,
furniture, automobiles, works of art, jewellery, shares, bonds, interests in a
business, other investments, pension funds, RRSPs, sums owing to you, etc.
Category Details Value
Total assets $__________
LIABILITIES
In the following table indicate all debts or financial commitments of any kind
as loans or granted as credit (hypothecary loans, personal loans, lines of credit,
credit cards, instalment sales, surety bonds, etc.) or that you must pay under a
statute (tax debts, contributions, dues or other unpaid duties, etc.) or under a
court decision (damages, support, overpayment of unemployment insurance or welfare
benefits, fines, etc.).
Indicate the amount of each debt, the balance of the principal and the name of the creditor.
Debt (Specify hypothec Balance Name of creditor
personal loan, credit
card, etc.)
1.
2.
3.
4.
Total liabilities $__________
Summary of assets and liabilities
Total assets: $__________
(less) _
Total liabilities: $__________
NET WORTH $__________
________________________________________
(signature)
Oath taken before __________(name and position, profession or quality)__________ at __________(municipality and province)__________, on __________(date)__________
(signature of person administering the oath)
