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Get Canada Schedule A to FL-17

SCHEDULE A to Form FL-17 STATEMENT OF INCOME ASSETS AND LIABILITIES This is the statement of income assets and liabilities of name the Plaintiff/Defendant in this action. A. INCOME All of my sources of income and amounts of income per month are as follows a Employment income of from employer b Employment insurance benefits of c Worker s Compensation Benefits of d Interest and investment income of e Pension income of f Government assistance income of g Self-employment income of h Other income of from source My total income last year as indicated at line 150 of my year tax return was I expect my income at line 150 of my tax return this year to be B. ASSETS Asset Particulars Real Estate List any interest in land including leasehold interests and mortgages whether or not you are registered as owner. Provide legal descriptions and indicate estimated market value of your interest without deducting encumbrances or costs of disposition* Record encumbrances under debts. 3STATE 1. v1 Date Acquired Value Estimated Vehicles List cars trucks motorcycles trailers motor homes boats etc* Financial Assets List savings and chequing accounts cash term deposits GICs stocks bonds Canada Savings Bonds mutual funds insurance policies indicate beneficiaries accounts receivable etc* Pensions and RRSPs Indicate name of institution where accounts are held name and address of pension plan and pension details. Corporate/Business Interests directly or indirectly in any corporation unincorporated business partnership trust joint venture etc* Other List anything else of value that you own including precious metals collections works of art jewellery or household items of high value. Include location of any safety deposit boxes. -3C. DEBTS Debt Incurred Balance Monthly Owing Payment Secured Debts List all mortgages lines of credit car loans and any other debt secured against an asset that you own* List all bank loans personal loans lines of credit overdrafts credit cards and any other debts that you have. List any other debts including obligations that are relevant to a claim for undue hardship e*g* car lease payment I name solemnly declare that the facts set out in this document are true. I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath. Declared before me to be true on date 20 year at city Alberta Commissioner for Oaths in and for the Province of Alberta Signature of the person making the solemn NOTE It is an offence to make a false declaration*. INCOME All of my sources of income and amounts of income per month are as follows a Employment income of from employer b Employment insurance benefits of c Worker s Compensation Benefits of d Interest and investment income of e Pension income of f Government assistance income of g Self-employment income of h Other income of from source My total income last year as indicated at line 150 of my year tax return was I expect my income at line 150 of my tax return this year to be B. ASSETS Asset Particulars Real Estate List any interest in land including leasehold interests and mortgages whether or not you are registered as owner. .

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