Income & Expense Report Form

First and Last Name(Required)

Month / Year(Required)

Email(Required)

Updated information or notes (e.g. new mailing address, employment, or phone number.)

Household Net Income

My Income

Net Employment Income

Spousal Support Received

Child Support Received

Canada Child Benefit (CCB)

* CCB is collected but not included in total income calculation.

Employment Insurance (EI)

Government Pension (CPP/OAS)

Other Pension Income

Social Assistance Benefits

Disability Benefits

Other Income

Total (My Income)

Other Family Member Income

Net Employment Income

Spousal Support Received

Child Support Received

Canada Child Benefit (CCB)

* CCB is collected but not included in total income calculation.

Employment Insurance (EI)

Government Pension (CPP/OAS)

Other Pension Income

Social Assistance Benefits

Disability Benefits

Other Income

Total (Other Family Member Income)

Total

Non-Discretionary Expenses

Child Support

Spousal Support

Childcare

Employment Expenses

Total

Medical Expenses (Not Covered by Insurance)

Prescriptions

Medical

Dental

Vision care

Other

Total

Summary

Monthly Surplus / Shortfall

Attestation & Signature

I affirm that this is a true and complete statement of my income and non-discretionary expenses this month. I have disclosed all income, from all sources, that I have earned, or received this month. I understand I must provide proof of income, and any non-discretionary and medical expenses.

Please upload all proof of employment income and any receipts for any non-discretionary expenses.

Drop files here or

Max. file size: 128 MB.

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Income & Expense Report Form

Household Net Income

Non-Discretionary Expenses

Medical Expenses (Not Covered by Insurance)

Summary