Today’s date:
Referred by:
Please complete to the best of your ability and return.
Full name:
Age:
Date of birth:
Place of birth:
Driver’s license no.:
Other ID (specify type & no.):
Resident address (#/street):
City/province/postal code:
If not, please specify alternate address or preferred method of communication:
Resided at current address since:
If less than 1 year, prior address:
Year you commenced living in Ontario:
Home Telephone:
Other (cell):
Email:
Fax No.:
Current employer:
Since (year):
Occupation(s):
Employer’s address (#/street):
City/province/postal code:
Work No.:
Fax No.:
Nature of matter:
Opposing Party’s Information
Full legal name of opposing party (i.e. the other side in the matter):
Opposing party’s relationship to you (i.e. spouse, former spouse, common-law etc.):
Opposing party’s date of birth (d/m/y):
Place of birth:
City/province/postal code:
Since (year):
Home No.:
Other (cell):
Email:
Opposing party’s employer:
Employer’s address:
Work No.:
Since (year):
Position/title:
Gross annual income:
S.I.N.
Date you commenced living together, if applicable (d/m/y):
If married, specify date (d/m/y):
Place:
Surname prior to marriage:
Surname at birth:
Opposing party’s surname prior to marriage:
and at birth:
If separated, indicate date of separation (d/m/y):
If divorced, indicate date of divorce (d/m/y):
If yes, please specify type of agreement:
Date entered into (d/m/y):
Full Name
Date of Birth (d,m,y) and Age
Gender
Grade
Educational Institution
Now Living with
Full Name
Date of Birth (d,m,y) and Age
Gender
Grade
Educational Institution
Now Living with
Do your child(ren) attend private school?
If so, please indicate any annual fees:
Is there a Court Order in place (re: child/spousal support, custody (decision-making responsibility), access (parenting time), division of property, etc.)?
Do you have an order for custody (decision-making responsibility) of the child(ren)? If so, date of order (d/m/y):
If so, date of order (d/m/y):
If so, please specify the access (parenting time) that you have (i.e. weekends, mid-week, shared (at least 40 % of the time) etc.):
Specify:
Religious upbringing of child(ren), if any?
Are any of the parties supporting a former spouse or child(ren) of another relationship?
Are the child(ren) in daycare/after school care?
Child
Care Provider
Address
Monthly Fee
Are the child(ren) enrolled in any extra-curricular activities (i.e. swimming, karate, etc.):
Child
Activity
Location
Monthly Fee
Are there any special concerns about the child(ren) eg. Health, or education?
Please specify – any extraordinary circumstances; possible changes in residence or employment; health concerns; other:
