Government of Ontario: Ministry of Community and Social Services

(Pursuant to Ontario Regulation 160/00 made under the Family Responsibility and Support Arrears Enforcement Act, 1996.)

• If you wish to receive a Director’s Statement of Arrears (statement of account), please attach a cheque or money order for $25.00 to this form or fill out the credit card section.
• Make the cheque or money order payable to Family Responsibility Office.
• Mail payment and form to address below:

Family Responsibility Office, P.O. Box 696, Downsview ON M3M 3A9

Please do not send regular support payments to this address

Please print your name:

Case Number

Telephone Number

Support Payor's Name

Support Recipient's Name

Credit Card Number

Credit Card Expiry Date (MM/YY)

Name of Cardholder

Authorized Signature

Date