F-6.2 REG 1 Appendix FORM A [Clause 4(a)] IN THE PROVINCIAL

F-6.2 REG 1
FAMILY MAINTENANCE, 1998
Appendix
FORM A
[Clause 4(a)]
IN THE PROVINCIAL COURT
OF SASKATCHEWAN
BETWEEN:
CLAIMANT
AND
RESPONDENT
Notice of Application
TO THIS HONOURABLE COURT:
CLAIM
1.
I/We ask this Honourable Court for the following relief:
of this form that are not applicable to your claim)
(leave blank any parts
______ An Order for maintenance for a child or a person mentioned in section 4 of The
______ Family Maintenance Act, 1997 in accordance with the table;
______ An Order for special or extraordinary expenses, as described in the Child
______ Support Guidelines, for a child or a person mentioned in section 4 of The
______ Family Maintenance Act, 1997 respecting the following expenses and in the
following amounts: ___________________________________________________ ;
______
______
______
______
An Order for maintenance for a child or a person mentioned in section 4 of The
Family Maintenance Act, 1997 not in accordance with the table, in the amount
of $ ________________ per ____ (week, month, etc., either for an indefinite or
limited period, or until a specified event occurs, or a lump sum) because:
______
______
maintenance is sought for a son or daughter over the age of 18 years
and the amount in accordance with the table would be inappropriate;
______
______
______
an order for child maintenance in an amount in accordance with the
table would cause undue hardship, as described in the Child
Support Guidelines;
______
______
______
an order for child maintenance in an amount in accordance with the
table would be inequitable given special provisions that have been
made for the benefit of the child;
______
______
______
the claimant/respondent exercises a right of access to, or has
physical custody of, the child/person for not less than 40% of the time
over the course of a year;
______
______
the income of the respondent is less than the minimum income
incorporated in the table;
______
other: (specify) _______________________________________________ ;
______ An order imputing income to the respondent in accordance with section 19 of
______ the Child Support Guidelines, in the following amount and for the following
______ reasons: ______________________________________________________________
______ ______________________________________________________________________
F-6.2 REG 1
FAMILY MAINTENANCE, 1998
______ An order for spousal maintenance in the amount of $ _________ per _______
(week, month, etc., either for an indefinite or limited period, or until a _____
______ specified event occurs, or a lump sum);
______ An order that maintenance be paid for a specified period before the date of the
______ order as follows:
Amount
Name of Dependant
Time Period
$ ______ per ______
________________________
__________________
$ ______ per ______
________________________
__________________
$ ______ per ______
________________________
__________________
$ ______ per ______
________________________
__________________
______ An order that the respondent designate his or her dependant, ____________ ,
______ as beneficiary of the respondent’s life insurance policy either:
_____ irrevocably; or
_____ until _____________________ ,
(a specific date)
______ and that the respondent pay all premiums on that life insurance policy;
______ An order that the respondent, who has an interest in a pension plan or other
______ benefit plan, designate his or her dependant, ___________________________ ,
______ as a beneficiary under the plan: ________________________________________ ;
(describe plan)
______ Where this application requests maintenance for a child, an order that the
______ father pay in addition:
_____ (a) expenses of the mother of the child with respect to prenatal care
_____ and birth of the child, in the amount of $ ________________________ ;
_____ (b) maintenance for the mother of the child in the amount of $ ____
_____ per _________ for _____________________________________________ ;
(a period not exceeding three months immediately preceding the birth of the child)
_____ (c) maintenance for the mother of the child in the amount of $ ____
_____ per _________ for _____________________________________________ ;
(period after the birth of the child, not exceeding six months)
______ Costs of the Application;
______ That payment pursuant to the order be secured as follows: ________________
______________________________________________________________________ .
F-6.2 REG 1
FAMILY MAINTENANCE, 1998
SUMMARY OF FACTS
2.
Where the application is for child maintenance:
_____ I claim maintenance for the following child(ren):
Name
Date of Birth
_____________________________
____________________________________
_____________________________
____________________________________
_____________________________
____________________________________
_____________________________
____________________________________
______ The nature of my relationship to and interest in the above child(ren) is as
______ follows: _______________________________________________________________
______ ______________________________________________________________________
______ The respondent is a parent of the above child(ren) based on the following
______ grounds: (refer to specific sections of The Family Maintenance Act, 1997)
______ ______________________________________________________________________
______ ______________________________________________________________________
______ As mother of the above child(ren), I claim maintenance and/or expenses for
______ myself, based on clause 9(1)(f) of The Family Maintenance Act, 1997.
3.
Where the application is for maintenance for a person described in section 4 of
The Family Maintenance Act, 1997:
______ I claim maintenance for the following person(s) described in section 4 of The
______ Family Maintenance Act, 1997:
4.
Name
Date of Birth
_____________________________
____________________________________
_____________________________
____________________________________
_____________________________
____________________________________
_____________________________
____________________________________
Where the application is for spousal maintenance:
______ The respondent is the claimant’s spouse based on the following grounds: (refer
______ to specific sections of The Family Maintenance Act, 1997)
______ ______________________________________________________________________
______ ______________________________________________________________________
FAMILY MAINTENANCE, 1998
5.
F-6.2 REG 1
The Financial Statement of the claimant is attached to this Notice. (A
Financial Statement need not be filed if maintenance is sought only for a spouse
and the parties consent to waive this requirement, in which case the Waiver of
Financial Statements must be signed by you and your spouse and filed with the
court. If an application is made for maintenance pursuant to section 3 or 4 of
The Family Maintenance Act, 1997, the Child Support Guidelines require the
following information to be filed:
Part I of the Financial Statement: by the respondent on all applications;
by the claimant on all applications where the claimant’s income
information is required by the court.
Parts II and III of the Financial Statement: by the claimant and
respondent in all applications where undue hardship or other exceptions
to the table are claimed.)
_____ Financial Statement
_____ Waiver of Financial Statements
_____ Maintenance for a child or a person mentioned in section 4 of The
_____ Family Maintenance Act, 1997 is sought in accordance with the table.
6.
Where the application is for maintenance for a child or a person mentioned in
section 4 of The Family Maintenance Act, 1997:
_____ I estimate the respondent’s annual income to be $ ________________ ;
_____ the respondent’s province of residence is ________________________ ;
_____ additional income should be imputed to the respondent pursuant to
_____ section 19 of the Child Support Guidelines for the following reasons:
_____ ______________________________________________________________ .
MEDIATION
7.
The mediation facilities used to negotiate maintenance issues in dispute in this
matter are as follows:
________________________________________________________________________
________________________________________________________________________
MAINTENANCE AGREEMENTS
8.
The details of any written or oral maintenance agreements between the parties
are: ____________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
(Indicate the date of the agreement or arrangement, whether the agreement or arrangement is now
in effect, the maintenance provisions in the agreement or arrangement, and, if there are arrears of
payment of maintenance, the amount of the arrears. Where it is requested that provisions of an
agreement be incorporated in the order, refer to the specific provisions to be incorporated.)
Dated at ______________ this _____________________ day of ______________ , _____ .
___________________________________
(Signature of Claimant or Claimant’s Lawyer)
F-6.2 REG 1
FAMILY MAINTENANCE, 1998
STATEMENT OF LAWYER
I, ______________________________ , lawyer for the claimant, ____________________ ,
(name of lawyer)
(name of claimant)
certify to this Court that I have complied with the requirements of subsection 16(1) of
The Family Maintenance Act, 1997 with respect to mediation. (Where the circumstances
of the case are of such a nature that it would clearly not be appropriate to so comply, set
out the circumstances.)
Dated at ______________ this _____________________ day of ______________ , _____ .
___________________________________
(Signature of Lawyer)
This document was delivered by _________________ , ____________________ , and the
(firm name)
(business address)
address for service is:
Lawyer in charge of file:
Telephone:
(Or, where claimant is not represented by a lawyer:)
This document was delivered by _________________
(claimant)
______________________________________________ ,
(telephone)
and the address for service is:
of __________________________ ,
(business or residence address)