ONTARIO

Court File Number

Superior Court of Justice, Family Court

(Name of court)

at

59 Church Street, St. Catharines, Ontario, L2R 7N8

(Court office address)

Form 13.1: Financial

Statement (Property and
Support Claims)
sworn/affirmed
February 23, 2015

Applicant(s)
Full legal name & address for service street & number, municipality,
postal code, telephone & fax numbers and e-mail address (if any).

Lawyers name & address street & number, municipality, postal code,
telephone & fax numbers and e-mail address (if any).

ALLEY S. MCBEAL
Fish & Bowl
Barristers and Solicitors
55 Main Street West
Grimsby, Ontario, L3M 1R3
Tel: 905-945-9271
Fax: 905-945-3066

Wilma Elizabeth Flintstone

25 Light Street
St. Catharines, Ontario, L4K 5T7

Respondent(s)
Full legal name & address for service street & number, municipality,
postal code, telephone & fax numbers and e-mail address (if any).

Lawyers name & address street & number, municipality, postal code,
telephone & fax numbers and e-mail address (if any).

JOHN B. SMART
Barrister and Solicitor
105 Queen Street West
Welland, Ontario, L3B 2S1
Tel: 905-735-2211
Fax: 905-735-2232

Frederick Alexander Flintstone

222 Poor Street
St. Catharines, Ontario, L4K 5T6

INSTRUCTIONS
1.

USE THIS FORM IF:

you are making or responding to a claim for property or exclusive possession of the matrimonial home and its contents; or

2.

you are making or responding to a claim for property or exclusive possession of the matrimonial home and its contents
together with other claims for relief.
USE FORM 13 INSTEAD OF THIS FORM IF:

you are making or responding to a claim for support but NOT making or responding to a claim for property or exclusive
possession of the matrimonial home and its contents.
3. If you have income that is not shown in Part I of the financial statement (for example, partnership income, dividends, rental
income, capital gains or RRSP income), you must also complete Schedule A.
4. If you or the other party has sought a contribution towards special or extraordinary expenses for the child(ren), you must also
complete Schedule B.
NOTE: You must fully and truthfully complete this financial statement, including any applicable schedules. Failure to do so may
result in serious consequences.

1. My name is (full legal name)

I live in (municipality & province)

Wilma Elizabeth Flintstone

St. Catharines, the Regional Municipality of Niagara, Province of Ontario

and I swear/affirm that the following is true:

FLR 13 (February 1, 2010)

www.DIVORCEmate.com

Form 13.1:

Financial Statement (Property and

Support Claims)

(page 2)

Court File Number:

PART I: INCOME
2. I am currently

employed by (name and address of employer)

Bettys Diner
321 Rubble Street
St. Catharines, Ontario, L3M 5G7
self-employed, carrying on business under the name of (name and address of business)
unemployed since (date when last employed)

3. I attach proof of my year-to-date income from all sources, including my most recent (attach all that are applicable):

pay cheque stub

social assistance stub

pension stub

workers compensation stub

employment insurance stub and last Record of Employment

statement of income and expenses/ professional activities (for self-employed individuals)
other (e.g. a letter from your employer confirming all income received to date this year)
4. Last year, my gross income from all sources was $

38,000.00

(do not subtract any taxes that have been

deducted from this income).

5.

I am attaching all of the following required documents to this financial statement as proof of my income
over the past three years, if they have not already been provided:

a copy of my personal income tax returns for each of the past three taxation years, including any
materials that were filed with the returns. (Income tax returns must be served but should NOT be filed in the
continuing record, unless they are filed with a motion to refrain a drivers license suspension.)

a copy of my notices of assessment and any notices of reassessment for each of the past three
taxation years;

where my notices of assessment and reassessment are unavailable for any of the past three taxation
years, an Income and Deductions printout from the Canada Revenue Agency for each of those years,
whether or not I filed an income tax return.
Note: An Income and Deductions printout is available from Canada Revenue Agency. Please call customer
service at 1-800-959-8281.

OR
I am an Indian within the meaning of the Indian Act (Canada) and I have chosen not to file income
tax returns for the past three years. I am attaching the following proof of income for the last three years (list
documents you have provided):

(In this table you must show all of the income that you are currently receiving.)

1.
2.

Income Source
Employment income (before deductions)
Commissions, tips and bonuses

Amount Received/Month

2916.67

Form 13.1:

3.
4.
5.
6.
7.
8.
9.
10.
11.

Financial Statement (Property and

Support Claims)

(page 3)

Court File Number:

Self-employment income (Monthly amount before expenses: $ )

Employment Insurance benefits
Workers compensation benefits
Social assistance income (including ODSP payments)
Interest and investment income
Pension income (including CPP and OAS)
Spousal support received from a former spouse/partner
Child Tax Benefits or Tax Rebates (e.g. GST)
Other sources of income (e.g. RRSP withdrawals, capital gains) (*attach Schedule A

250.00

and divide annual amount by 12)

12.
13.

14.

$3166.67
$38,000.04

Total monthly income from all sources:

Total monthly income X 12 = Total annual income:

Other Benefits

Provide details of any non-cash benefits that your employer provides to you or are paid for by your business such as medical
insurance coverage, the use of a company car, or room and board.

Item

Details

Yearly Market Value

Total
PART 2: EXPENSES
EXPENSE
Automatic Deductions
CPP contributions
EI premiums
Income taxes
Employee pension contributions
Union dues
SUBTOTAL
Housing
Rent or mortgage
Property taxes
Property insurance
Condominium fees
Repairs and maintenance
SUBTOTAL
Utilities
Water

Monthly Amount

129.94
54.83
322.02

$506.79
1,100.00
300.00
62.50
100.00

$1,562.50
80.00

$0.00

Form 13.1:

Financial Statement (Property and

Support Claims)

Heat
Electricity
Telephone
Cell phone
Cable
Internet

(page 4)

90.00
120.00
50.00
65.00
60.00

SUBTOTAL
Household Expenses
Groceries
Household supplies
Meals outside the home
Pet care
Laundry and Dry Cleaning

$465.00

SUBTOTAL

$576.61

Childcare Costs
Daycare expense
Babysitting costs

398.36
50.00
108.25
20.00

200.00

SUBTOTAL
Transportation
Public transit, taxis
Gas and oil
Car insurance and license
Repairs and maintenance
Parking
Car Loan or Lease Payments

$200.00

SUBTOTAL

$441.00

Health
Health insurance premiums
Dental expenses
Medicine and drugs
Eye care

230.00
156.00
55.00

61.67
30.00

SUBTOTAL
Personal
Clothing
Hair care and beauty
Alcohol and tobacco
Education (specify)
Entertainment/recreation (including
children)
Gifts

$91.67

SUBTOTAL

$148.33

25.00
40.00
50.00
33.33

Court File Number:

Form 13.1:

Financial Statement (Property and

Support Claims)

Other expenses
Life insurance premiums
RRSP/RESP withdrawals
Vacations
School fees and supplies
Clothing for children
Childrens activities
Summer camp expenses
Debt payments
Support paid for other children
Other expenses not shown above
(specify)

SUBTOTAL
Total Amount of Monthly Expenses
Total Amount of Yearly Expenses

(page 5)

30.00
103.92
75.00
200.00
41.67
50.00
40.00

$540.59
$4532.49
$54,389.88

Court File Number:

Form 13.1:

Financial Statement (Property and

Support Claims)

(page 6)

Court File Number:

PART 3: OTHER INCOME EARNERS IN THE HOME

Complete this part only if you are making or responding to a claim for undue hardship or spousal support. Check and complete all
sections that apply to your circumstances.

1.

I live alone.

2.

I am living with (full legal name of person you are married to or cohabiting with)

3.

I/we live with the following other adult(s):

4.

I/we have (give number)

5.

My spouse/partner

of child(ren) who live(s) in the home.

works at (place of work or business)
does not work outside the home.

6.

My spouse/partner

earns (give amount) $

per

does not earn any income.

7.

My spouse/partner or other adult residing in the home contributes about $

per

towards the household expenses.

PART 4: ASSETS IN AND OUT OF ONTARIO

If any sections of Parts 4 to 9 do not apply, do not leave blank, print NONE in the section.

The date of marriage is: (give date)

January 1, 2000

The valuation date is: (give date)

August 10, 2014

The date of commencement of cohabitation is (if different from date of marriage): (give date)
PART 4(a): LAND
Include any interest in land owned on the dates in each of the columns below, including leasehold interests and mortgages. Show
estimated market value of your interest, but do not deduct encumbrances or costs of disposition; these encumbrances and costs
should be shown under Part 5 Debts and Other Liabilities.

Nature & Type of

Ownership
(Give your percentage
interest where relevant.)

Matrimonial Home, with

a 50% interest

Estimated Market value of YOUR interest

Address of Property

on date of
marriage

123 Dino Drive, St. Catharines, Ontario,

L2K 4R5 joint ownership, total value
$180,000.00

15. TOTAL VALUE OF LAND

$0.00

on valuation
date

today

90,000.00

90,000.00

$90,000.00

$90,000.00

Form 13.1:

Financial Statement (Property and

Support Claims)

(page 7)

Court File Number:

PART 4(b): GENERAL HOUSEHOLD ITEMS AND VEHICLES

Show estimated market value, not the cost of replacement for these items owned on the dates in each of the columns below. Do not
deduct encumbrances or costs of disposition; these encumbrances and costs should be shown under Part 5, Debts and Other
Liabilities.

Description

Item

Household
goods
& furniture

Furnishings and household contents

joint ownership, total value $4,000.00

Cars, boats,
vehicles

2009 Pontiac Vibe

Indicate if
NOT in
your
possession

Estimated Market value of YOUR interest

on date of
on valuation
today
marriage
date

2,000.00

2,000.00

16,000.00

16,000.00

12,000.00

12,000.00

$30,000.00

$30,000.00

Jewellery, art,
electronics,
tools,
sports
&
hobby,
equipment
Other special Royal Doulton Collection - Inheritance
items

16. TOTAL VALUE OF GENERAL HOUSEHOLD ITEMS AND VEHICLES

$0.00

PART 4(c): BANK ACCOUNTS, SAVINGS, SECURITIES AND PENSIONS

Show the items owned on the dates in each of the columns below by category, for example, cash, accounts in financial institutions,
pensions, registered retirement or other savings plans, deposit receipts, any other savings, bonds, warrants, options, notes and other
securities. Give your best estimate of the market value of the securities if the items were to be sold on the open market.

Amount / Estimated Market Value

on date of
on valuation
today
marriage
date

INSTITUTION (including location)/

DESCRIPTION (including issuer and date)

Account
number

Chequing

Royal Bank of Canada sole account

557889

1,500.00

0.00

0.00

Savings

Bedrock Credit Union Savings

Account joint ownership, total value
$10,000.00

45456

0.00

5,000.00

5,000.00

$0.00

$5,000.00

$5,000.00

Category

17. TOTAL VALUE OF ACCOUNTS, SAVINGS, SECURITIES AND

PENSIONS

Form 13.1:

Financial Statement (Property and

Support Claims)

(page 8)

Court File Number:

PART 4(d): LIFE & DISABILITY INSURANCE

List all policies in existence on the dates in each of the columns below.

Company, Type &

Policy No.

Owner

London Life Insurance Wilma

Company Policy No.
4445344

Beneficiary

Katelyn
Rubble, in
trust for
children

Face
Amount

Cash Surrender Value

on date of
on valuation
today
marriage
date

$100,000.00

nil

$0.00

18. TOTAL CASH SURRENDER VALUE OF INSURANCE POLICIES

$0.00

$0.00

PART 4(e): BUSINESS INTERESTS

Show any interest in an unincorporated business owned on the dates in each of the columns below. An interest in an incorporated
business may be shown here or under BANK ACCOUNTS, SAVINGS, SECURITIES AND PENSIONS in Part 4(c). Give your best
estimate of market value of your interest.

Name of Firm or
Company

Interest

Estimated Market value of YOUR interest

on date of
on valuation
today
marriage
date

$0.00

19. TOTAL VALUE OF BUSINESS INTERESTS

$0.00

$0.00

PART 4(f): MONEY OWED TO YOU

Give details of all money that other persons owe to you on the dates in each of the columns below, whether because of business or
from personal dealings. Include any court judgments in your favour, any estate money and any income tax refunds owed to you.

Amount Owed to You

on date of
on valuation
today
marriage
date

Details

$0.00

20. TOTAL OF MONEY OWED TO YOU

$0.00

$0.00

PART 4(g): OTHER PROPERTY

Show other property or assets owned on the dates in each of the columns below. Include property of any kind not listed above. Give
your best estimate of market value.

Category

Details

Estimated Market Value of YOUR interest

on date of
on valuation
today
marriage
date

21. TOTAL OF OTHER PROPERTY

$0.00

$0.00

$0.00

22. VALUE OF ALL PROPERTY OWNED ON THE VALUATION DATE

(Add items [15] to [21].)

$0.00

$0.00

$0.00

Form 13.1:

Financial Statement (Property and

Support Claims)

(page 9)

Court File Number:

PART 5: DEBTS AND OTHER LIABILITIES

Show your debts and other liabilities on the dates in each of the columns below. List them by category such as mortgages, charges,
liens, notes, credit cards, and accounts payable. Dont forget to include:
any money owed to the Canada Revenue Agency;
contingent liabilities such as guarantees or warranties given by you (but indicate that they are contingent); and

any unpaid legal or professional bills as result of this case.

Category

Details

on date of
marriage

Bedrock Credit Union for

matrimonial home (acct#44565)
joint owners, total value
$100,000.00
Bedrock Credit Union Line of
Credit (acct#2223456) joint
owners, total value $9,000.00
Bedrock Credit Union
MasterCard (acct # 2234 5555
6666 7777) joint owners, total
value $6,000.00

Mortgage
Line of Credit
Credit Card

23. TOTAL OF DEBTS AND OTHER LIABILITIES

$0.00

Amount owing
on valuation
date

today

50,000.00

50,000.00

4,500.00

4,500.00

3,000.00

3,000.00

$57,500.00

$57,500.00

PART 6: PROPERTY, DEBTS AND OTHER LIABILITIES ON DATE OF MARRIAGE

Show by category the value of your property, debts and other liabilities, calculated as of the date of your marriage. (In this part, do not
include the value of a matrimonial home or debts or other liabilities directly related to its purchase or significant improvement, if you
and your spouse ordinarily occupied this property as your family residence at the time of separation.)

Value on date of marriage

Category and details

Assets

Land
General household items & vehicles
Bank accounts, savings, securities, pensions
Royal Bank of Canada sole account
Life & disability insurance
Business interests
Money owed to you
Other property (Specify.)

Liabilities

$0.00
$0.00
$1,500.00
$0.00
$0.00
$0.00
$0.00

Debts and other liabilities (Specify.)

$0.00
TOTALS

24. NET VALUE OF PROPERTY OWNED ON DATE OF MARRIAGE

$1,500.00
$1,500.00

(From the total of the Assets column, subtract the total of the Liabilities column.)

25. VALUE OF ALL DEDUCTIONS (Add items [23] and [24].)

$59,000.00

$0.00

Form 13.1:

Financial Statement (Property and

Support Claims)

(page 10)

Court File Number:

PART 7: EXCLUDED PROPERTY

Show by category the value of property owned on the valuation date that is excluded from the definition of net family property (such
as gifts or inheritances received after marriage).

Category

Value on valuation
date

Details

Inheritance

Royal Doulton Collection from grandmothers

estate

26. TOTAL VALUE OF EXCLUDED PROPERTY

12,000.00

$12,000.00

PART 8: DISPOSED-OF PROPERTY

Show by category the value of all property that you disposed of during the two years immediately preceding the making of this
statement, or during the marriage, whichever period is shorter.

Category

Details

Value

27. TOTAL VALUE OF DISPOSED-OF PROPERTY

$0.00

PART 9: CALCULATION OF NET FAMILY PROPERTY

Deductions
Value of all property owned on valuation date (from item [22] above)

$59,000.00
$12,000.00

Subtract value of all deductions (from item [25] above)

Subtract total value of all excluded property (from item [26] above)

28. NET FAMILY PROPERTY

BALANCE

$125,000.00
$66,000.00
$54,000.00
$54,000.00

NOTE: This financial statement must be updated no more than 30 days before any court event by either completing and filing:
a new financial statement with updated information, or
an affidavit in Form 14A setting out the details of any minor changes or confirming that the information contained in this statement
remains correct.

Sworn/Affirmed before me at

The Town of Grimsby

(municipality)

in

The Province of Ontario

(province, state or country)

on

February 23, 2015

(date)
Commissioner for taking affidavits
(Type or print name below if signature is illegible.)

WILMA ELIZABETH FLINTSTONE

(This form to be signed in front of a lawyer,
justice of the peace, notary public or
commissioner for taking affidavits.)

Form 13.1:

Financial Statement (Property and

Support Claims)

(page 11)

PART 2: EXPENSES
PROPOSED BUDGET
EXPENSE
Automatic Deductions
CPP contributions
EI premiums
Income taxes
Employee pension contributions
Union dues

Monthly Amount

SUBTOTAL
Housing
Rent or mortgage
Property taxes
Property insurance
Condominium fees
Repairs and maintenance

$0.00

SUBTOTAL

$0.00

SUBTOTAL
Household Expenses
Groceries
Household supplies
Meals outside the home
Pet care
Laundry and Dry Cleaning

$0.00

SUBTOTAL

$0.00

SUBTOTAL
Transportation
Public transit, taxis
Gas and oil
Car insurance and license
Repairs and maintenance
Parking
Car Loan or Lease Payments

$0.00

SUBTOTAL

$0.00

Utilities
Water
Heat
Electricity
Telephone
Cell phone
Cable
Internet

Childcare Costs
Daycare expense
Babysitting costs

Court File Number:

Form 13.1:

Financial Statement (Property and

Support Claims)

(page 12)

Health
Health insurance premiums
Dental expenses
Medicine and drugs
Eye care
SUBTOTAL
Personal
Clothing
Hair care and beauty
Alcohol and tobacco
Education (specify)
Entertainment/recreation (including
children)
Gifts

$0.00

SUBTOTAL
Other expenses
Life insurance premiums
RRSP/RESP withdrawals
Vacations
School fees and supplies
Clothing for children
Childrens activities
Summer camp expenses
Debt payments
Support paid for other children
Other expenses not shown above

$0.00

(specify)

SUBTOTAL

$0.00

Total Amount of Monthly Expenses:

$0.00
$0.00

Total Amount of Yearly Expenses:

Court File Number:

Form 13.1:

Financial Statement (Property and

Support Claims)

(page 13)

Court File Number:

Form 13.1:

Financial Statement (Property and

Support Claims)

(page 14)

Court File Number:

FINANCIAL STATEMENT
SUMMARY PAGE
BUDGET
Income
Income From All Sources
Other Benefits

Monthly
+
Total Monthly Income and Benefits

Expenses
Automatic Deductions
Housing
Utilities
Household
Childcare Costs
Transportation
Health
Personal
Other

Actual

$0.00
$0.00
$0.00
Proposed

Total Expenses

$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

Monthly Surplus / (Deficit)

$0.00

$0.00

NET FAMILY PROPERTY

Assets
Land
General Household Items and Vehicles
Bank Accounts, Savings, Securities and Pensions
Life and Disability Insurance
Business Interests
Money Owed to You
Other Property
Deductions
Debts and Other Liabilities on Valuation Date
Net Value of Property Owned on Date of Marriage
Exclusions
Excluded Property owned on Valuation Date

Valuation Date
[15]
[16]
[17]
[18]
[19]
[20]
[21]
Total Assets [22]

$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

[23]
[24]
Total Deductions [25]

$0.00
$0.00
$0.00

[26]

$0.00

Net Family Property

$0.00

([Assets] minus [Deductions] minus [Exclusions])

Notes:

Schedule A
Additional Sources of Income
Line
1.
2.
3.
4.
5.
6.

Income Source

Annual Amount

Net partnership income

Net rental income (Gross annual rental income of $ )
Total amount of dividends received from taxable Canadian corporations
Total capital gains ($ ) less capital losses ($ )
Registered retirement savings plan withdrawals
Any other income (specify source)

Subtotal

$0.00

Schedule B
Special or Extraordinary Expenses for the Child(ren)
Childs Name

Expense

Amount/yr.

Available Tax
Credits or
Deductions*

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Total Net Annual Amount
Total Net Monthly Amount

$0.00
$0.00

* Some of these expenses can be claimed in a parents income tax return in relation to a tax credit or deduction
(for example childcare costs). These credits or deductions must be shown in the above chart.
I attach proof of the above expenses.
I earn $

per year which should be used to determine my share of the above expenses.

NOTE:
Pursuant to the Child Support Guidelines, a court can order that the parents of a child share the costs of the following
expenses for the child:

Necessary childcare expenses;

Medical insurance premiums and certain health-related expenses for the child that cost more than $100
annually;

Extraordinary expenses for the childs education;

Post-secondary school expenses; and,

Extraordinary expenses for extracurricular activities.