Financial Statement

2063
This form must be completed by the person who owes a debt to Aide financire aux tudes, if
requested by the collection officer in charge of his or her file.

Section

Personal
Information
Personal Information

Last name

Permanent code assigned by the Ministre

First name

Social insurance number

Date of birth
Y

Number

Direction

Street

Apartment

(North, South, East, West)

Municipality

Municipality (cont.)

Postal code

Province

Telephone number (home)

Area code

E-mail address

Section

Marital
Status
Marital Status

Single
Married

De facto spouse
Civil union spouse

Divorced
Widowed

Legally separated
De facto separated

Number of dependents

Spouses last name and first name (optional)

Social insurance number

Spouses occupation
Spouses monthly income $ ____________________________ /month

Section

Occupation
Occupation
Name of employer

Occupation

Number

Street

Municipality

Ministre de lducation, du Loisir et du Sport

Aide financire aux tudes

Province

Postal code

Telephone number (office)

Area code

1035, rue De La Chevrotire

Qubec (Qubec) G1R 5A5

22-1603A (rev. 08-06)

Section

Financial
Situation
Financial Situation
ASSETS

LIABILITIES

Cash balance $ ____________________________

Client accounts $ ____________________________
Property $ ____________________________
Furnishings $ ____________________________
Investments ____________________________$
(RRSP, dividends, etc.) $ ____________________________
Vehicle $ ____________________________
Other $ ____________________________
TOTAL $ ____________________________

MONTHLY INCOME

Mortgage loan
Vehicle loan
Student loan*
Other

$____________________________
$____________________________
$____________________________
$____________________________
$____________________________
$____________________________
$____________________________
TOTAL $____________________________

MONTHLY EXPENSES

(Attach proof of income.)

Gross earnings $ ____________________________

Net earnings $ ____________________________
Employment insurance since ________________________ (date)
_
$ ____________________________
Employment assistance since ________________________ (date)
_
$ ____________________________
Rental income $ ____________________________
Support payments $ ____________________________
Family allowance $ ____________________________
Commissions and tips $ ____________________________
Pensions and annuities $ ____________________________
Investment income $ ____________________________
Other $ ____________________________
TOTAL $ ____________________________

Student loan*
Mortgage payment (principal + interest)
Rent
Taxes (municipal and school)
Insurance (home, car, life)
Heating and lighting
Cable and telephone
Food
Clothing
Support payments
Childcare expenses
Transportation (car, bus)
Other
TOTAL

$____________________________
$____________________________
$____________________________
$____________________________
$____________________________
$____________________________
$____________________________
$____________________________
$____________________________
$____________________________
$____________________________
$____________________________
$____________________________
$____________________________

*You must enter this amount. If you do not know it, contact the collection officer in charge of your file.

Section

Debts
Debts

Mortgage

Creditors name

Address
Expiry date

Address (cont.)

Rent
Landlords telephone number

Landlords name

Area code

Vehicle
Creditors name

Address

Address (cont.)

Monthly payment

Expiry date
Y

Make and year

Other debts
Type of debt

Creditors name

Amount

Due date
Y

Monthly payment
M

$
Type of debt

Creditors name

$
Amount

Due date
Y

Monthly payment
M

Section

Signature
Signature

I hereby certify that the information provided is accurate and complete.

Date
Y

Signature X