FORM 72C
rule 72.02(4)
JUDGMENT DEBTOR'S STATEMENT OF FINANCIAL SITUATION
[heading as in originating process]
	To [judgment debtor]:
	of [address]
	You are required to complete this form by giving the information requested below.  The completed form signed by you must be sent to [judgment creditor] at [address for service] before [day for hearing named in the summons].  If you do not do this, the Court may make an order that you attend before the Court and give the information.  
								
Signature of judgment creditor's solicitor:
	1.	Amount and Source of Weekly Income
	Occupation:						__________________
	If working for an employer:
	Name and address of employer:			__________________
	Gross wage:						__________________
	Current overtime (if any):				__________________
	Car and other allowances and
	  commission						__________________
	If self-employed or in partnership:
	Average pre-tax earnings for last
	  12 months:						__________________
	If unemployed:
	State length of last employment,
	  date when last employment ceased
	  and gross weekly amount earned:		__________________
	Pension or other benefit received:
	Workers' compensation received:
	Maintenance received:
	Superannuation received: 
	Board or rent received:				__________________
	Average weekly interest on deposits 
	 in ADIs (e.g. banks, credit unions or 
	 building societies), debentures etc.:		__________________
	Average weekly dividend on shares:		__________________
	Other income (give particulars):			__________________
	Total Gross Weekly Income:			__________________
2.	Property and Assets
	Land, including vacant land:
	For each piece of land:
	Market value:						_____________
	Amount of mortgage:		_____________	_____________
	Net value:
	Motor vehicle:
	For each motor vehicle:
	Year, make and model: 	         ______________________________
	Amount owing to finance company:			_____________
	Net value: Deposits in ADIs 
	 (e.g. banks, credit unions, building societies etc.):	_____________
	Other investments including shares,
	debentures, bonds:
	Money owing to you:
	From        , $
	From        , $
	Total:
	Value of interest in partnership or business:
	Furniture, household and personal goods:
	Market value
	Amount owing to finance company
	Net value:
	Life insurance policies:
	Give particulars and state surrender value of each
	  policy:
	Other assets (give particulars):
	Total Property and Assets:
3.	Debts, Liabilities and Other Financial Obligations
(a)	Weekly expenses
Income tax:								_____________
Superannuation:							_____________
Housing (mortgage, rent, board, hospital
  or institution):							_____________
Local government rates:						_____________
Water and sewerage rates:					_____________
Land tax:								_____________
Child care expenses incurred for the
  purpose of earning income:					_____________
Maintenance actually paid:						_____________
Instalment payments such as for household goods or tools of trade:
To		,	$
To		,	$
Total:									_____________
Electricity and gas:							_____________
Food:									_____________
Other general household expenses:				_____________
Motor vehicle expenses (registration,
  insurance, maintenance, fuel):					_____________
Fares:									_____________
Telephone:								_____________
Insurance policy premiums:					_____________
School fees and other school expenses:				_____________
Clothing and shoes:							_____________
Medical and chemist expenses:					_____________
Entertainment:							_____________
Payments on court orders and fines:				_____________
Other expenses (give particulars):				_____________
Total:									_____________
(b)	Other debts outstanding
	Give particulars of debts under hire purchase, leasing credit card or other credit contracts, department store accounts, guarantee or personal loan:
$	, to		, due on
$	, to		, due on
Total:									_____________
	4.	If any of the assets referred to in paragraph 2 above is owned jointly, identify each asset and give the name of the other owner or owners:
	..	..	..	..	..	..	..	..	..	..	..
	..	..	..	..	..	..	..	..	..	..	..
	5.	If any of the debts referred to in paragraph 3 is due jointly, identify each debt and give the name of the other debtor or debtors:
	..	..	..	..	..	..	..	..	..	..	..
	..	..	..	..	..	..	..	..	..	..	..
	6.	Give particulars of any other circumstances which affect the financial situation of the judgment debtor such as the number and age of dependants, marital status and health:
	..	..	..	..	..	..	..	..	..	..	..
	..	..	..	..	..	..	...	..	..	..	..
Signature of judgment debtor:
Date: