Child Support Determination Form
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7SCHEDULE I
(s. 3)
CANADA
CHILD SUPPORT
Province of Québec
DETERMINATION FORM
District of ________________________
FORM:
father
File No. _____________________
mother
produced jointly
established by the court
prepared on_______ _______ _______
Year
Month
Day
Please complete in block letters
The parents may complete the form together and must provide all required documents. If they do not complete the form
together, the parent who completes the form must provide all information and documents in respect of himself or
herself. That parent may also indicate any known information about the other parent.
DO NOT STAPLE DOCUMENTS TO THE FORM
Part 1 – Identification
100
Surname _______________________________________
Given name(s) __________________________
(Father’s identification)
101
Surname _______________________________________
Given name(s) __________________________
(Mother’s identification)
Indicate the date of birth of each common child of the parents in respect of whom the application is made.
102
______ ______ ______
104
______ ______ ______
106
______ ______ ______
Year
Month
Day
Year
Month
Day
Year
Month
Day
103
______ ______ ______
105
______ ______ ______
107
______ ______ ______
Year
Month
Day
Year
Month
Day
Year
Month
Day
Part 2 – Statement of parents’ income
Indicate income for the current year or foreseeable income for the next 12 months, as the case may be. Provide a copy of the provincial income tax return filed in
accordance with the Taxation Act (chapter I-3) and the provincial assessment notice of the Minister of Revenue for the last fiscal year _____ or, if the income tax return
has not been filed or the notice has not been sent, provide a copy of the federal income tax return filed in accordance with the Income Tax Act (R.S.C., 1985, c. 1 (5th
Supp.)) and the federal assessment notice of the Minister of National Revenue for the last fiscal year _____. Also provide the requested documents and any other
document used to establish income.
FATHER
MOTHER
Gross salary
200
___________
___________
(Provide the last three pay slips)
Commissions/tips
201
___________
___________
Net income from a business or self-employment
202
___________
___________
(Gross income less expenses relating to the business or self-employment)
(Provide financial statements)
Employment insurance benefits and parental insurance benefits
203
___________
___________
Support paid by a third party and received for own needs
204
___________
___________
Retirement or disability benefits, or other benefits
205
___________
___________
Interest, dividends, and other investment income
206
___________
___________
(Write taxable amount of dividends filed in the provincial income tax return or,
where applicable, in the federal income tax return)
Net rentals
207
___________
___________
(Gross rental income less expenses associated with the rental of immovables)
(Provide a statement of income and expenses for each immovable)
Other income
208
___________
___________
(Excluding family-related government transfers, last-resort financial assistance benefits
and any sums granted by the Minister of Education, Recreation and Sports
under a financial assistance program for education expenses)
(Please specify: _______________________________ )
TOTAL
209
___________
___________
(Add lines 200 to 208)
(2014-04)
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