Child support determination form - Quebec
SCHEDULE I
(s. 3)
CANADA CHILD SUPPORT
Province of Québec DETERMINATION FORM
District of
File No.
Fill Out in Block Letters
The parents may complete this form together and attach the documents required. Otherwise, the
parent completing it shall provide the information and documents concerning himself. He may also
indicate the information he knows about the other parent.
Part 1 – Identification
100 Family name Given name(s)
(father’s identification)
101 Family name Given name(s)
(mother’s identification)
Indicate the date of birth of each child covered by the application
102 105
Year Month Day Year Month Day
103 106
Year Month Day Year Month Day
104 107
Year Month Day Year Month Day
Part 2 – Statement of parents’ income
(Indicate the income for the current year or, as the case may be, the foreseeable income for the 12 coming months.
Attach a copy of the provincial and federal income tax returns and the assessment notices for the last fiscal year )
FATHER MOTHER
200 Gross salary
(attach pay slip)
201 Commissions/tips
202 Net income from a business or self-employment
(attach financial statements)
203 Employment insurance benefits
204 Support paid by a third party and received for one’s own needs
205 Retirement, disability benefits or others
206 Interest and dividends and other investment income
207 Net rents
(attach a statement of income and expenses respecting the immovable)
208 Other income
(except family government transfers,
income security benefits and APPORT benefits)
(specify: )
209 TOTAL
(add lines 200 to 208)
SJ-789A (97-05)
1
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