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PERSONAL DATA

Surname:__________________________________________________________

Given Names: __________________________________________________________

S.I.N. __________________________________________________________

Birth date: (Y/M/D) _____________________________________________

Street Address:__________________________________________________________

Town/City:__________________________________________________________

Province: ________________________________________________________________

Postal Code: _____________________________________________

Telephone: (Home) ________________Telephone: (Bus.)_______________________

I have resided at the above address since: Year Month Day ______________

I have resided in this province since: Year Month Day _______________

Mailing Address (if different):_________________________________________________

Present Occupation: _______________________________________________________

Full Name and Address of Present Employer: ____________________________________

(including postal code) _____________________________________________________

You have been employed since when? _________________________________________

Marital Status: Married: Widowed: Common-law: Separated: Single: Divorced:
(specify month and year of event if it occurred in last five years):
________________________________________________________________

Full name and address of spouse: _____________________________________________

______________________________________________________________________

Birth date of spouse: _____________________________________________

Spouse's S.I.N.: _____________________________________________

Number of dependents who rely on you for financial support:

NAME OF DEPENDENTS	RELATIONSHIP	BIRTH DATE	ADDRESS OF DEPENDENT
1.	1.	1.	1.
2.	2.	2.	2.
3.	3.	3.	3.
4.	4.	4.	4.

PERSONAL DATA

List all of your employers, showing dates started and terminated, for the past two years. If there were periods when you were drawing E.I.. benefits, show each period separately.

Have you ever been bankrupt, either in Canada or elsewhere of filed a proposal under the Bankruptcy and Insolvency Act?  Yes/ No

If yes, give:

Name of Trustee: _____________________________________________

Date of bankruptcy: _____________________________________________

Place of assignment: _____________________________________________

Date of discharge/Certificate of Full Performance: _____________________________________________

Is there a copy available? _________________

Have you been self-employed in the last five (5) years? Yes/ No

Names of partners? _____________________________________________

Place of business (city)? _____________________________________________

Nature of business? _____________________________________

Do you have a GST number? # _____________Payroll Remittance #__________________

If yes, are there any returns outstanding? Yes No

What year? _____________________________________________

Are you an officer or a director of a limited company? Yes/ No

If yes, give details. _____________________________________________
 
 
 

MONTHLY INCOME

Your net earnings (take home Pay).....................$________________

Net earnings of spouse if living with you ........... $________________

Rents from tenants or boarders .......................$________________

Pensions .............................................$________________

Allowance ............................................$________________

Employment Insurance Benefits ........................$________________

Other income (including Child Tax benefit ) ..........$________________

Social Assistance ....................................$________________

TOTAL ................................................$________________

Monthly Non-Discretionary Expenses:
Medical Condition Expenses ...........................$________________

Family court payments ................................$________________

Child care payments ..................................$________________

Expenses as a condition of employment ................$________________

Other (Specify) ......................................$________________

Total ..................................................................................................$________________

MONTHLY EXPENSE

Rent, Mortgage or board payments......................$________________

Fire insurance on house ..............................$________________

Fuel .................................................$________________

Food .................................................$________________

Clothing .............................................$________________

Life Insurance .......................................$________________

Car Insurance  .......................................$________________

Gas (cooking and/or hot water) .......................$________________

Electricity ..........................................$________________

Water ................................................$________________

Telephone ............................................$________________

Medical and Hospital Insurance .......................$________________

Automotive Operating Expenses.........................$________________

Transportation to and from work.......................$________________

Laundry and dry cleaning .............................$________________

Miscellaneous:........................................$________________

TOTAL ................................................$________________

TOTAL - Surplus (Shortfall)..............................................................$________________
 
 

______________________Asset Description________________________	__Est. Value___
Cash on Hand/In Bank	1.
Household Furniture	2.
Vehicle & Serial Number	3.
Retirement Savings Plans / (RRSP)	4.
Loans Due to you/Accounts Receivable	5.
Cash Surrender Value of Insurance Policies	6.
Saving Plans/Bonds	7.
Personal Effects/Jewellery	8.
Stocks/Shares	9.
Estimated Tax Refund	10.
Collectable (stamps, coins etc.)	11.
House/Cottage/Land (Sole/Joint/Part Owner)	12.
Mobile Home	13.
Motorcycle (Model/Serial #)	14.
Boat/Trailer	15.
Other Assets/Tools of the Trade	16.

 

DEBTS
List all debts, including secured debts and utilities.

_______Creditor's Name ____	________Full Address________	Account No.	Amount Owed
1.	1.	1.	1.
2.	2.	2.	2.
3.	3.	3.	3.
4.	4.	4.	4.
5.	5.	5.	5.
6.	6.	6.	6.
7	7.	7.	7.
8	8.	8.	8.
9	9.	9.	9.
10.	10	10.	10.
11.	11.	11.	11.
12.	12.	12.	12.
13.	13.	13.	13.
14.	14.	14.	14.
15.	15.	15.	15.
16.	16.	16.	16.

Have any of the above debts arisen from your guarantee or co-signing of debts for another individual or corporation? Yes/ No

If yes, please indicate:
Lender's Name

Lender's Address ________________________________________________

Amount________________________________________________

Borrower's Name________________________________________________

Borrower's Address________________________________________________

Is borrower bankrupt? Yes/ No

GENERAL

1. Within the last twelve (12) months, have you sold, disposed of or transferred any of your assets, either in Canada or elsewhere? Yes No

(eg. vehicles, RRSP's, stocks/bonds, furniture)

Description  of Asset	Date  Disposed	To Whom	Proceeds	Disposition  of Proceeds

2. Within the last twelve (12) months, have you made payments
in excess of regular payments to any creditor, either in Canada or elsewhere? Yes/ No
 

3. Within the last twelve (12) months, have you had any assets
seized by a creditor, either in Canada or elsewhere? Yes/ No

Asset seized

Date seized

Name of party seized by

Was party who made seizure a secured creditor? Yes/ No

Form of security?

4. Do you expect to receive any sums of money, or any other property within the next 12 months, which are not related to your normal income?   Yes______       No_______

____________________________________________________________________________________________

____________________________________________________________________________________________

5. Within the last five years, while you knew yourself to be insolovent, have you sold, disposed of , or transferred any real estate?
 

Description of Asset	Date Disposed	To Whom	Proceeds	Disposition of Proceeds
.	.	.	.	.
.	.	.	.	.
.	.	.	.	.

6. Within the last five (5) years, while you know yourself to be insolvent,  have you made any gifts to relatives or others in excess of $500.00? Yes/ No

7. Have you made any arrangements to continue to pay any creditors in the future? Yes/ No

8. (a) Please list the banks that you are currently dealing with:

(b) Do you have a safety deposit box? Yes/ No

If so, which bank?

Please provide details of the contents:
 
 
 

9. Does anyone owe you any money? Yes/ No. Provide details.

(a) Personal loans

(b) Accounts receivable

(c) Agreement for sale

(d) Other

10. Do you currently own any of the following?

(a) Collectibles (stamps,coins, art, antiques, etc.) Yes/ No

(b) Savings bonds (owned presently or being purchased on a payroll savings plan). Yes/ No

(c) R.R.S.P.'s Yes/ No

(d) Shares (owned presently or being purchased on a payroll savings plan). Yes/ No

Please provide details if answer is Yes.
 
 

(e) Personal life insurance policies Yes/ No (please include a copy of your life insurance policy).
 
 

	Policy No. 1	Policy No. 2
i) Life Insurance Company
ii) Beneficiary
iii) Cash Surrender Value

11. Are you a beneficiary of a will or will you receive an inheritance? Yes/ No

12. Has anyone started legal proceedings against you? Yes/ No

If yes, give details.
 
 

13. Do any of your debts arise from:

A fine or penalty imposed by court? Yes/ No

A recognizance or bail bond? Yes/ No

Alimony or maintenance payments? Yes/ No

Fraud, embezzlement, misappropriation? Yes/ No

Defalcation while acting in a fiduciary capacity? Yes/ No

Obtaining property by false pretences/ fraudulent misrepresentation? Yes/ No

14. For which year did you file your last income tax return?

Did you receive a refund? Yes/ No

Are there arrears owing? Yes/ No

Is there a copy available? Yes/ No

15. Are you paying/receiving any alimony or maintenance? Yes/ No

If yes, to/from whom Amount since January 1st $____________
Please provide a copy of the Court Order or separation agreement.
 
 
 

16. Please describe briefly, the circumstances which caused your financial difficulties.

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS A TRUE, CORRECT AND COMPLETE STATEMENT THAT FULLY DISCLOSES THE STATE OF MY ASSETS AND LIABILITIES.
 
 
 
 

Signature ________________________________Date ________________
 
 

1. Application - complete all questions
 

2. Vehicles - copy of vehicle registration
 

3. Agreements - debentures, mortgages, separation, alimony, child support, leases, sales contracts, judgements, fines, wage assignments, court order.
 

4. Life Insurance - copy of all policies - (cash surrender value not exempt)
 

5. Stock/Bonds/Securities - all pertinent documentation/statements /RRSP's
 

6. Pay Stubs - most current one available - if you are/were on UIC please supply all stubs for current year, as well as the UIC office address where application was made
 

7. Tax Information - copy of last return filed - if you have not filed up to date, please provide information for Trustee to file any previous years (T4's, receipts, etc.) - re current year - a list of all employers with gross earnings and deductions made for tax, CPP, UIC, union dues and any maintenance/support payments and spousal earnings.
 

8. Credit Cards - all must be turned over to the Trustee, including those with a nil balance
 

9. Initial Payment to Bankruptcy Estate (to cover filing fees, mailings, etc.)
$ ________(by cash, certified cheque or money order only)
 

10. Postdated cheques ________@_____________