Individual Affidavit Form
In the matter of (insert estate number(s) or estate name(s) from the Unclaimed Dividends Database) for unclaimed dividends held by the Receiver General, I swear or say under penalty of perjury:
- That I am entitled to the unclaimed dividends specified in the claim attached hereto, as I am the individual creditor to whom the funds held are payable, or his or her legal representative;
- That I have knowledge of all the circumstances connected with this claim;
- That I have reason to believe that the Receiver General for Canada holds unclaimed dividends to which I am entitled in the amount of $ ;
- That I have not been reimbursed by a third party and the amounts are still owed to me;
- That I am entitled to request payment of the unclaimed dividend held in trust pursuant to subsection 154(1) of the Bankruptcy and Insolvency Act;
- That I claim the unclaimed dividend pursuant to subsection 154(2) of the Bankruptcy and Insolvency Act;
- That I agree and undertake to indemnify Her Majesty and her officers, officials, employees and agents if it is determined that I was not entitled to the funds;
- That I live or that I have lived at (insert address from Unclaimed Dividends Database); and
- That the content of the attached Claim Form and supporting documents is accurate and true.
Sworn before me in the city of in the province of this day of , 20.
Commissioner of Oaths
Creditor or legal representative
Print name or stamp
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