1-877-433-0963
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:

































































































































































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