A. INFORMATION RELATING TO THE AFFAIRS OF THE BANKRUPT/DEBTOR
| 1. Family name: |
Given names: |
Date of birth |
|
YesNo |
|
2. Also known as:
|
3. Complete address, including postal code:
|
| 4. Marital status: |
MarriedSingleWidowedSeparatedDivorcedPartner |
5. Full name of spouse or common-law partner:
|
6. present employer:
|
Occupation:
|
7A. Number of persons
|
7B. 17 years of age or younger:
|
8. Have you operated a business within the last five years?
|
YesNo |
type and period of operation:
|
B. WITHIN 12 MONTHS PRIOR TO THE DATE OF THE INITIAL BANKRUPTCY EVENT, HAVE YOU, EITHER IN CANADA OR ELSEWHERE:
|
| 9A. Sold or disposed of any of your property? |
YesNo |
| 9B. Made payments in excess of the regular payments to creditors? |
YesNo |
| 9C. Had any property seized by a creditor? |
YesNo |
C. WITHIN FIVE YEARS PRIOR TO THE DATE OF THE INITIAL BANKRUPTCY EVENT, HAVE YOU, EITHER IN CANADA OR ELSEWHERE:
|
| 10A. Sold or disposed of any property? |
YesNo |
| 10B. Made any gifts to relatives or others in excess of $500? |
YesNo |
D. BUDGET INFORMATION: Attach Form 65 to this form
|
| 11A. Have you ever made a proposal under the Bankruptcy and Insolvency Act? |
YesNo |
| 11B. Have you been bankrupt before in Canada? |
YesNo |
|
(If yes, provide the following details for all insolvency proceedings:
(a) filing date and location of the proceedings;
(b) name of trustee or administrator;
(c) if applicable, was the proposal successful;
(d) date on which Certificate of Full Performance or Discharge was obtained.)
|
| 12. Do you expect to receive any sums of money that are not related to your normal income, or any other property within the next 12 months? |
YesNo |
13. If you answered Yes to any of questions 8, 9 or 11, provide details:
|
14. Give reasons for your financial difficulties:
|