MOVING EXPENSES STATEMENT
(Criteria: Must have moved at least 40 kms within Canada to earn employment or self-employment income or to study in an educational institution.)
         
Name _______________________________
  
S.I.N. ____________________
  
Year _______
           
  Former address in full   New address in full    
Address ___________________________   ___________________________    
City, Province ___________________________   ___________________________    
Postal Code ___________________________   ___________________________    
           
  Former employer, business
or educational institution		   New employer, business
or educational institution		    
Name ___________________________   ___________________________    
Address ___________________________   ___________________________    
City, Province ___________________________   ___________________________    
Postal Code ___________________________   ___________________________    
Date of Move: ___________________________        
Distance from former residence
to new work or study location
___________ kms		   Distance from new residence
to new work or study location		   ___________ kms
           
           
Costs:          
Moving of household effects (mover: ___________________)   $ ___________    
Transportation costs from
  former residence to new
(mode of travel: _____________)		  
$ ___________		    
  Travel costs (# of kms: _______ )   $ ___________    
  Lodging (# of nights: _______ )   $ ___________    
  Meals (# of days: _______ )   $ ___________    
Temporary living expenses near
  new or old location (max. 15 days)		    
$ ___________		    
  Lodging (# of nights: _______ )   $ ___________    
  Meals (# of days: _______ )   $ ___________    
Cost of lease settlement     $ ___________    
Selling costs of former residence (selling price: $ _____________ )   $ ___________    
  Real estate commission     $ ___________    
  Legal or notarial fees     $ ___________    
  Advertising     $ ___________    
  Other (please specify: _____________)   $ ___________    
Purchase costs of new residence     $ ___________    
  Legal fees     $ ___________    
  Taxes (registration or transfer of title)     $ ___________    
           
TOTAL expenses     $ ___________ (A)    
Amount reimbursed by employer     $ ___________ (B)    
Net moving claim     $ ___________ (A-B)