Form 78 — Statement of Affairs (Business Bankruptcy)

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(Paragraph 158(d) of the Act)

This form may not be completed online. It is provided here for reference purposes only.

(Title Form 1)

To the bankrupt:

You are required to carefully and accurately complete this Form and the applicable attachments, showing the state of your affairs on the date of your bankruptcy, on the Space to insert day of month day of Space to insert month Space to insert year. When completed, this Form and the applicable attached lists will constitute your Statement of Affairs and must be verified by oath or solemn declaration.

Liabilities

(as stated and estimated by bankrupt)

  1. Unsecured creditors as per list "A"
$Space to insert Liabilities to unsecured creditors
  1. Secured creditors as per list "B"
 Space to insert Liabilities to Secured creditors
  1. Preferred creditors as per list "C"
 Space to insert Liabilities to Preferred creditors
  1. Contingent, trust claims or other liabilities as per list "D" estimated to be reclaimable for
 Space to insert Contingent, trust claims or other liabilities
 
Space to insert total of the above liabililites
Total liabilities
$Space to insert total liabililites
Surplus
$Space to insert Surplus

I, Space to insert name of bankrupt, of the Space to insert day of month of Space to insert month in the Province of Space to insert year, do swear (or solemnly declare) that this statement and the attached lists are to the best of my knowledge a full, true and complete statement of my affairs on the Space to insert day of month day of Space to insert month Space to insert year and fully disclose all property of every description that is in my possession or that may devolve on me in accordance with section 67 of the Act.

Sworn (or Solemnly declared)

before me at Space to insert city, town or village (city, town or village)

in the Province of Space to insert name of province ,

on this Space to insert day of month day of Space to insert month Space to insert year.

Space to insert signature of Commissioner of Oaths
Commissioner of Oaths
Space to insert signature of bankrupt
(Signature of bankrupt)

for the Province of Space to insert name of province

Assets

(As stated and estimated by bankrupt)

  1. Inventory
$Space to insert value of inventory
  1. Trade fixtures, etc.
Space to insert value of Trade fixtures, etc.
  1. Accounts receivable and other receivables, as per List "E"
Space to insert Accounts receivable and other receivables
Good
$Space to insert value of goods
Doubtful
Space to insert doubtful assets
Bad
Space to insert bad assets
Estimated to produce
Space to insert estimated assets to produce
  1. Bills of exchange, promissory note, etc., as per List "F"
Space to insert value of bills of exchange, promissory note, etc.
  1. Deposits in Financial Institutions
Space to insert value of deposits in financial institutions
  1. Cash
Space to insert value of cash
  1. Livestock
Space to insert value of livestock
  1. Machinery, equipment and plant
Space to insert value of machinery, equipment and plant
  1. Real property or immovable as per List "G"
Space to insert value of real property or immovable
  1. Furniture
Space to insert value of furniture
  1. RRSPs, RRIFs, Life insurance, etc.
Space to insert value of RRSPs, RRIFs, Life insurance, etc.
  1. Securities (Shares, Bonds, Debentures, etc.)
Space to insert value of securities (shares, bonds, debentures, etc.)
  1. Interests under wills
Space to insert interests under wills
  1. Vehicles
Space to insert value of vehicles
  1. Other property, as per List "H"
Space to insert details of first property
Space to insert value of first property
Space to insert details of second property
Space to insert value of second property
Space to insert total value of second property
 
Space to insert total value of all properties
If bankrupt is a corporation, add:
Amount of subscribed capital
$Space to insert amount of subscribed capital
Amount paid on capital
Space to insert amount paid on capital
 
Space to insert total capital
$Space to insert balance subscribed and unpaid
Balance subscribed and unpaid
$Space to insert
Estimated to produce
Space to insert estimated assets to produce
 
Space to insert
Total assets
$Space to insert total value of assets
Deficiency
$Space to insert amount of deficiency

List "A"

Unsecured Creditors

The names to be arranged in alphabetical order and numbered consecutively.

List of Unsecured Creditors
No. Name of creditor Address Amount of Claim
       
Space to insert bankrupt's signature of list A
Bankrupt
Space to insert date of list A
Date

List "B"

Secured Creditors

List of Secured Creditors
No. Name of creditor Address Amount of Claim Particulars of Security When given Estimated value of security Estimated surplus from security Balance of claim unsecured
                 
Space to insert bankrupt's signature of list B
Bankrupt
Space to insert date of list B
Date

List "C"

Preferred Creditors for Wages, Rent, etc.

List of Preferred Creditors for Wages, Rent, etc.
No. Name of creditor Address and occupation Nature of Claim Period during which claim accrued Amount of claim Amount payable in full Difference ranking for dividend
               
Space to insert bankrupt's signature of list C
Bankrupt
Space to insert date of list C
Date

List "D"

Contingent or Other Liabilities

Give particulars of claims not set out in List "B", or "C".

Contingent or Other Liabilities
No. Name of creditor or claimant Address and occupation Amount of liability or claim Amount expected to rank for dividend Date when liability incurred Nature of liability
             
Space to insert bankrupt's signature of list D
Bankrupt
Space to insert date of list D
Date

List "E"

List of Debts Due to the Bankrupt
No. Name of debtor Address and occupation Nature of debt Amount of debt (good, doubtful, bad) Folio of ledgers or other book where particulars to be found When contracted Estimated to produce Particulars of any securities held for debt
                 
Space to insert bankrupt's signature of list E
Bankrupt
Space to insert date of list E
Date

List "F"

Bills of Exchange, Promissory Notes, Lien Notes, Chattel Mortgages, etc., Available as Assets

List of Bills of Exchange, Promissory Notes, Lien Notes, Chattel Mortgages, etc., Available as Assets
No. Name of all promissory, acceptors, endorsers, mortgagors and guarantors Address Occupations Amount of bill or note, etc. Date when due Estimated to produce Particular of any property held as security for payment of bill or note, etc.
               
Space to insert bankrupt's signature of list F
Bankrupt
Space to insert date of list F
Date

List "G"

Real Property or Immovable Owned by Bankrupt

List of Secured Creditors
Description of property Nature of bankrupt’s interest In whose name does title stand Total value Particulars of mortgages, hypothecs, or other encumbrances
(Name, Address, Amount)		 Equity or surplus
           
Space to insert bankrupt's signature of list G
Bankrupt
Space to insert date of list G
Date

List "H"

Property

Give full particulars of property of every description that is in the bankrupt's or that may devolve on the bankrupt in accordance with section 67 of the Act and that are not included in any other list.

Full statement of property
Nature of Property Location Details of property Original cost Estimated to produce

(a) Stock-in-trade

        

(b) Trade fixtures, etc.

        

(c) Cash in Financial Institution (name) (address)

        

(d) Cash on hand

        

(e) Livestock

        

(f) Machinery, equipment and plant

        

(g) Furniture

        

(h) Life insurance policies, RRSPs etc.

        

(I) Securities

        

(j) Interests under wills, etc.

        

(k) Vehicles

        

(l) Taxes

        

(m) Other property (state particulars)

        
Space to insert bankrupt's signature of list H
Bankrupt
Space to insert date of list H
Date
Note:
If a copy of this Notice is sent electronically by means such as email, the name and contact information of the sender, prescribed in Form 1.1, must be added at the end of the document.

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