A. INFORMATION RELATING TO THE AFFAIRS OF THE BANKRUPT/DEBTOR
1. Family name: |
Given names: |
Date of birth |
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YesNo |
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2. Also known as:
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3. Complete address, including postal code:
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4. Marital status: |
MarriedSingleWidowedSeparatedDivorcedPartner |
5. Full name of spouse or common-law partner:
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6. present employer:
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Occupation:
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7A. Number of persons
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7B. 17 years of age or younger:
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8. Have you operated a business within the last five years?
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YesNo |
type and period of operation:
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B. WITHIN 12 MONTHS PRIOR TO THE DATE OF THE INITIAL BANKRUPTCY EVENT, HAVE YOU, EITHER IN CANADA OR ELSEWHERE:
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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:
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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
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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.)
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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:
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14. Give reasons for your financial difficulties:
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