Estate Identification
APPLICANT
SPOUSE
Surname:
Surname:
Given Names:
Given Names:
Also Known As:
Also Known As:
Mailing Address:
Mailing Address:
Postal Code:
Postal Code:
Physical Address:
Physical Address:
i.e. Lot and Concession:
i.e. Lot and Concession:
Township and County:
Township and County:
At the Address Since:
At the Address Since:
Occupation:
Occupation:
Part Time
Full Time
Retired
Unemployed
Part Time
Full Time
Retired
Unemployed
Employer:
Employer:
Telephone Home:
Telephone Home:
Telephone Work/Alternative:
Telephone Work/Alternative:
SIN:
Gender:
Male
Female
SIN:
Gender:
Male
Female
Birthdate:
/
/
Birthdate:
/
/
MARITAL STATUS (Specify month and year of event (YYMMDD) if it occurred in the last five years
MARITAL STATUS (Specify month and year of event (YYMMDD) if it occurred in the last five years
M.
Single
W.
Sep.
D.
CL.
M.
Single
W.
Sep.
D.
CL.
Number of Persons in Household Family Unit, Including Bankrupt?
DEPENDANTS:
Name
Age
Date of Birth
Relationship to You
APPLICANT
SPOUSE
Did you pay alimony or support during the past year?
Yes
No
Did you pay alimony or support during the past year?
Yes
No
If yes, to whom?
If yes, to whom?
Address:
Address:
Amount Paid:
Amount Paid:
Date of Separation:
Date of Separation:
Business and Trade Names
Have you operated a business in the last five years?
Yes
No
APPLICANT
SPOUSE
Self-Employed:
Self-Employed:
Owned Business:
Owned Business:
Debt incurred in business?
No
Yes
Debt incurred in business?
No
Yes
Percentage of total debts which relate to business:
Percentage of total debts which relate to business:
Business Name:
Business Name:
Address:
Address:
Year end date:
Year end date:
Date business closed:
Date business closed:
Guaranteed loans for business:
No
Yes
Guaranteed loans for business:
No
Yes
Type of business:
Type of business:
Type of Ownership:
Sole Proprietorship
Corporation
Partnership
Type of Ownership:
Sole Proprietorship
Corporation
Partnership
Partners:
Partners:
INCOME TAX INFORMATION
APPLICANT
ALL EMPLOYERS FOR PAST TWO YEARS STARTING WITH MOST RECENT
(Include Periods of UIC, Social Services and Pensions)
EMPLOYER'S NAME AND ADDRESS
DATE STARTED
DATE ENDED
SPOUSE
ALL EMPLOYERS FOR PAST TWO YEARS STARTING WITH MOST RECENT
(Include Periods of UIC, Social Services and Pensions)
EMPLOYER'S NAME AND ADDRESS
DATE STARTED
DATE ENDED
APPLICANT'S TAX INFORMATION
SPOUSE'S TAX INFORMATION
Year last return filed:
Year last return filed
Amount owing
Amount owing
Refund received
Refund received
Refund received
Refund received
RENT/PROPERTY TAXES PAID (PAST CALENDAR YEAR)
ADDRESS
RENT/OWN
NUMBER
OF MONTHS
AMOUNT
PAID
NAME OF LANDLORD/
MUNICIPALITY
Rent
Own
Rent
Own
Rent
Own
Rent
Own
Rent
Own
CAUSES OF INSOLVENCY:
In your own words, describe why you need to file a proposal/bankruptcy.
HAVE YOU PREVIOUSLY FILED A BANKRUPTCY OR PROPOSAL IN CANADA OR ELSEWHERE?
(SPECIFY)
APPLICANT
No
Yes
SPOUSE
No
Yes
TRUSTEE'S NAME
TRUSTEE'S NAME
BANKRUPTCY DATE
BANKRUPTCY DATE
BANKRUPT DISCHARGE DATE
BANKRUPT DISCHARGE DATE
PROPOSAL DATE
PROPOSAL DATE
RESULT OF PROPOSAL
RESULT OF PROPOSAL
PLACE FILED
PLACE FILED
ESTATE NO.
ESTATE NO.
APPLICANT
SPOUSE
HAVE YOU DISPOSED OF / TRANSFERRED ASSETS OR RRSP IN THE LAST 12 MONTHS?
(PROVIDE COPY OF RRSP)
WHEN
WHAT/PROCEEDS
WHERE DID PROCEEDS GO
Yes
No
Yes
No
HAVE YOU MADE ANY EXCESS PAYMENTS TO CREDITORS IN THE LAST 12 MONTHS?
DETAILS
Yes
No
Yes
No
HAVE YOU HAD ANY ASSETS SEIZED BY CREDITORS IN THE LAST 12 MONTHS?
DETAILS - WHEN
WHAT
WHO
Yes
No
Yes
No
HAVE YOU SOLD / DISPOSED OF / TRANSFERRED REAL ESTATE IN PAST 5 YEARS?
DETAILS - WHEN
DESCRIPTION
PROCEEDS
WHERE DID PROCEEDS GO?
Yes
No
Yes
No
HAVE YOU MADE GIFTS TO RELATIVES OVER $500.00 IN PAST 5 YEARS?
DETAILS
Yes
No
Yes
No
HAVE YOU MADE ARRANGEMENTS TO CONTINUE TO PAY ANY CREDITORS?
DETAILS
Yes
No
Yes
No
HAVE YOU BEEN OR ARE YOU INVOLVED IN CIVIL LITIGATION FROM WHICH YOU MAY RECEIVE MONIES OR PROPERTY?
DETAILS
Yes
No
Yes
No
DO YOU EXPECT TO RECEIVE ANY SUMS OF MONEY WHICH ARE NOT RELATED TO YOUR NORMAL INCOME, OR ANY OTHER PROPERTY WITHIN THE NEXT 12 MONTHS?
DETAILS
Yes
No
Yes
No
Indicate
Whose
Debt
Name of Creditor
Mailing Address
Include Postal Codes
Amount
Owing
Account #
Comments
Loans Cosigned or Guaranteed for Others
APPLICANT
SPOUSE
Lender's Name:
Lender's Name:
Address:
Address:
Borrower's Name:
Borrower's Name:
Address:
Address:
Real Estate Owned:
Real Estate:
None
House
Cottage
Land
Real Estate:
None
House
Cottage
Land
Legal Description:
Legal Description:
Bankrupt's Interest:
Bankrupt's Interest:
Title Holders:
Title Holders:
Value:
Value:
Secured Creditor(s):
Secured Creditor(s):
Real Estate Owned:
Real Estate:
None
House
Cottage
Land
Real Estate:
None
House
Cottage
Land
Legal Description:
Legal Description:
Bankrupt's Interest:
Bankrupt's Interest:
Title Holders:
Title Holders:
Value:
Value:
Secured Creditor(s):
Secured Creditor(s):
ASSETS OWNED:
APPLICANT
Current Value
SPOUSE
Current Value
Cash
Household Furniture
Personal Effects and Jewellery
Life Insurance Policies
(Please provide copy of policy)
Beneficiary:
Relation:
Policy #:
Name of Insurance Company:
Address:
Life Insurance Policies
(Please provide copy of policy)
Beneficiary:
Relation:
Policy #:
Name of Insurance Company:
Address:
Stocks/Bonds/CSB
RRSP
(Please provide copy of statement)
Holder of Plan:
Policy #
Address:
Automobile/Motorcycle
Year:
Make:
Model:
Loan:
Lease:
Name of Creditor:
Automobile/Motorcycle
Year:
Make:
Model:
Loan:
Lease:
Name of Creditor:
Recreation Vehicle
Snowmobile/Boats/Trailers
Year:
Make:
Model:
Secured Creditor:
Tools of Trade
Other Assets:
Details
BANK ACCOUNT INFORMATION
BANK
:
ACCOUNT #
STREET
CITY
POSTAL CODE
WHOSE NAME IS ACCOUNT IN JOINT
BANK ACCOUNT INFORMATION
BANK
:
ACCOUNT #
STREET
CITY
POSTAL CODE
WHOSE NAME IS ACCOUNT IN JOINT
OTHER:
Has the applicant or spouse any debts arising from:
APPLICANT
SPOUSE
Fine or penalty imposed by Court? (Including assault)
Yes
No
Yes
No
Recognizance or bail bond?
Yes
No
Yes
No
Alimony?
Yes
No
Yes
No
Maintenance of affiliation order?
Yes
No
Yes
No
Maintenance of support of separated family?
Yes
No
Yes
No
Fraud?
Yes
No
Yes
No
Embezzlement?
Yes
No
Yes
No
Misappropriation?
Yes
No
Yes
No
Defalcation while acting in a fiduciary capacity?
Yes
No
Yes
No
Property obtained by false means/fraud?
Yes
No
Yes
No
Student loans outstanding
Yes
No
Yes
No
DETAILS OF ABOVE DEBT
SUMMARY OF MONTNLY
INCOME AND EXPENSES
Information/Notes to the trustee:
NUMBER OF DEPENDANTS
IN HOUSEHOLD:
INCOME:
Take Home Salary
Pension
Spouse's Take Home Salary
Child Tax Benefit
Support Payments
Employment Insurance Benefits
Social Assistance
Rental Income
Other Income (Specify)
Gross Self-Employed
TOTAL MONTHLY INCOME
EXPENSES:
Child Support Payments-Applicant
- Spouse
Spousal Support Payments-Applicant
- Spouse
Child Care-Applicant
- Spouse
Health-Related Expenses-Applicant
- Spouse
Fines/Penalties Being Paid-Applicant
-Spouse
Employment-Related Exp.-Applicant
-Spouse
Income Tax . Applican
- Spouse
Rent/Mortgage Payment
Property Taxes/Condo Fees
Heating/Gas/Oil
Telephone/Internet
Cable/Satellite
Hydro
Water
Smoking
Alcohol
Dining/Lunch
Entertainment/Sports
Pets
Gifts/Donation
Allowances
Food/Grocery
Laundry/Dry Cleaning
Grooming/Toiletries
Clothing
Repairs/Maintenance/Gas
Public Transportation
Insurance - Vehicle
Insurance - House/Content
Insurance - Life
Spouse Debt Repayment
Payment to Estate
Spouse to Estate
Secured Creditor Payment
Other (Specify)
TOTAL MONTHLY EXPENSES
DIFFERENCE BETWEEN INCOME AND EXPENSES: