C-25, r. 5 - Regulation respecting the statement by parties in respect of applications relating to an obligation of support

Schedule Disposition versions

2012-09-01

SCHEDULE I

(s. 1)

CANADA

Province of Québec

District of

SWORN STATEMENT UNDER ARTICLE 827.5 OF THE CODE OF CIVIL PROCEDURE

File No.:

(Please complete in block letters)

IDENTITY: Applicant ( ) Defendant ( )

(1) Surname(s):

Given name(s):

(2) Surname at birth:

(3) Sex: M ( ) F ( )

(4) Language: French ( ) English ( )

(5) Residential address:

Postal code: Province: Country:

Telephone at home: ( ) At work: ( )

Postal address (if different):

Postal code: Province: Country:

(6) Date of birth (YYYY/MM/DD):

Social insurance number:

INFORMATION ON EMPLOYMENT AND INCOME

(7) Employee Self-employed worker:

Name and address of employer:

Postal code: Province: Country:

Remuneration:

Language of communication: French ( ) English ( )

(8) The deponent is unemployed: ( )

(9) The deponent receives income security benefits: ( ) File no. (CP 12):

(10) Other income:

(Indicate the source and amount of each)

OTHER INFORMATION

(11) Name at birth of deponent’s mother:

(12) Other name(s) used by the deponent:

(13) Indicate the nature and date of the application to which this statement is attached:

(14) If this statement is attached to an application for revision of support, indicate the date of the judgment awarding support (YYYY/MM/DD) and the file No., if different:

INFORMATION ON OTHER PARTY

(if it is known)

(15) Residential address:

(16) Telephone at home: At work:

(17) Date of birth: Social insurance number:

SWORN STATEMENT

I declare that the information given is true and complete, and I have signed:

At: on this day of

____________________________________________________

Deponent

Sworn before me at on this day of

____________________________________________________

Person authorized to administer oath

SJ-766 (06-96)

O.C. 1524-95, Sch. I; O.C. 212-97, s. 1.