FAMILY MEDIATION FORM 2:
INCOME & ASSETS WORKSHEET

Client Information

Your Name

(Fill in annual amount)

A. T1 and Assessments for the last 3 years

T1 Line 150 –Year 1:

T1 Line 150 –Year 2:

T1 Line 150 –Year 3:

T1 Assessment –Year 1:

T1 Assessment –Year 2:

T1 Assessment –Year 3:

B. Income

Employee

Paystubs or letter from employer reflecting year-to-date earnings:

Self-employed

Company financial statement –Year 1:

Company financial statement –Year 2:

Company financial statement –Year 3:

Statements showing salaries, wages, fees, payments or benefits to persons or corporations that are not at “arms length” minus amount necessary to earn income = amount –Year 1:

Statements showing salaries, wages, fees, payments or benefits to persons or corporations that are not at “arms length” minus amount necessary to earn income = amount –Year 2:

Statements showing salaries, wages, fees, payments or benefits to persons or corporations that are not at “arms length” minus amount necessary to earn income = amount –Year 3:

Partnership

Statement of income, draw and capital in the partnership –Year 1:

Statement of income, draw and capital in the partnership –Year 2:

Statement of income, draw and capital in the partnership –Year 3:

Corporations (taxable amount of dividends received is replaced by actual amount received)

Corporation and subsidiaries’ financial statement –Year 1:

Corporation and subsidiaries’ financial statement –Year 2:

Corporation and subsidiaries’ financial statement –Year 3:

Statements showing salaries, wages, fees, payments or benefits to persons or corporations that are not at “arms length” minus amount necessary to earn income = amount –Year 1:

Statements showing salaries, wages, fees, payments or benefits to persons or corporations that are not at “arms length” minus amount necessary to earn income = amount –Year 2:

Statements showing salaries, wages, fees, payments or benefits to persons or corporations that are not at “arms length” minus amount necessary to earn income = amount –Year 3:

Beneficiary of a trust (provide copy of trust settlement agreement)

Trust financial statement –Year 1:

Trust financial statement –Year 2:

Trust financial statement –Year 3:

Employment insurance

Paystubs or letter reflecting year-to-date earnings:

Social assistance (the amount attributable to the spouse)

Paystubs or letter reflecting year-to-date earnings:

Pension

Paystubs or letter reflecting year-to-date earnings:

Workers compensation

Paystubs or letter reflecting year-to-date earnings:

Disability payments

Paystubs or letter reflecting year-to-date earnings:

Shares

Value of shares sold minus value when acquired minus cost to acquire = amount:

Capital gains

Actual gains minus losses minus taxable gains = amount (may be excluded if non-recurring):

Other income and benefits added to income (Interest, investment income, rental income, student bursaries, student loan –attributable to living expenses, wrongful dismissal proceeds minus expenses, interest earned on a personal injury settlement, RRSP withdrawals, etc.)

Income 1 Description

Income 1 Amount:

Income 2 Description

Income 2 Amount:

Income 3 Description

Income 3 Amount:

Income 4 Description

Income 4 Amount:

Income 5 Description

Income 5 Amount:

Income 6 Description

Income 6 Amount:

Income 7 Description

Income 7 Amount:

Income 8 Description

Income 8 Amount:

Income 9 Description

Income 9 Amount:

Income 10 Description

Income 10 Amount:

TOTAL:

C. Other income with special considerations

Signing bonus:

Performance bonus:

Commission:

Severance payments:

Vacation payments:

Forgivable loan from employer:

D. Tax Benefits and Rebates

Amount of Child Tax Benefit:

GST rebates:

E. Deductions

Employment expenses

Teacher’s exchange fund contribution:

Expenses of railway employees:

Sales expenses:

Transport employee’s expenses:

Travel expenses:

Motor vehicle travel expenses:

CPP and EI paid to an employee:

Salary reimbursement:

Forfeited amounts:

Musical instruments:

Artists’ employment expenses:

Union and professional dues:

CPP contributions and EI premiums paid for a substitute for or an assistant to the spouse:

Child support received and included in line 150:

Spousal support received from other spouse and included in line 150:

Social assistance received for others besides the spouse and included in line 150:

Capital gains (taxable amount realized is replaced by actual amount in excess of losses):

Business losses:

Carrying charges and interest deductible under the Income Tax Act:

Self-employment earnings from a prior year, net of reserves:

Allowable capital cost with respect to real property:

Property acquired by a partnership or sole proprietorship income reinvestment for purposes of capitalization:

TOTAL:

F. Special Expenses

Income

Spousal support received:

UCCB for children who are the ones SE is being requested for that are in line 150:

TOTAL:

Deductions

Spousal support paid:

UCCB for children who are not the ones SE is being requested for that are in line 150:

TOTAL:

G. Spousal or Parental Support

Income

Child support received:

Social assistance received for others besides the spouse and not included in line 150:

Child Tax Benefit:

BC Family Bonus:

TOTAL:

Assets and Liabilities Worksheet

List the following assets and approximate value if known (use separate sheet if necessary)

Principal residence:

Recreational property:

Income property:

Vehicles:

Recreational vehicles:

Personal items 1:

Personal items 2:

Personal items 3:

Art/jewelry/collectibles 1:

Art/jewelry/collectibles 2:

Art/jewelry/collectibles 3:

Art/jewelry/collectibles 4:

Other shared items 1:

Other shared items 2:

Other shared items 3:

Enter present value of the following assets.

RESPs:

RRSPs:

RRIFs:

Other registered savings plans:

Employment pension plan:

Bank accounts and GICs:

Stocks:

Bonds:

Mutual funds:

Deferred profit sharing plans:

Other business interests:

Cash value of life insurance:

Other financial assets:

Other money owed to you:

Enter present value of the following liabilities.

Principal residence mortgage:

Recreational property mortgage:

Income property mortgage:

Loans for automobiles:

Credit card #1 balance:

Credit card #2 balance:

Credit card #3 balance:

Credit card #4 balance:

Other deferred payment plans:

Student loans:

Loans against life insurance policy:

Other loans or lines of credit:

Taxes owing:

Please attach any additional support files here.