Form 78—Statement of Affairs (Business Bankruptcy)
For persons to which the 2009 amendments do not apply
(Paragraph 158(d) of the Act)
(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 day of . When completed, this Form and the applicable attached lists will constitute your Statement of Affairs and must be verified by oath or solemn declaration.
(as stated and estimated by bankrupt)
- Unsecured creditors as per list "A"
- Secured creditors as per list "B"
- Preferred creditors as per list "C"
- Contingent, trust claims or other liabilities as per list "D" estimated to be reclaimable for
I, , of the of in the Province of , 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 day of 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 (city, town or village)
in the Province of ,
on this day of .
Commissioner of Oaths
(Signature of bankrupt)
for the Province of .
(As stated and estimated by bankrupt)
- Trade fixtures, etc.
- Accounts receivable and other receivables, as per List "E"
- Bills of exchange, promissory note, etc., as per List "F"
- Deposits in Financial Institutions
- Machinery, equipment and plant
- Real property or immovable as per List "G"
- RRSPs, RRIFs, Life insurance, etc.
- Securities (Shares, Bonds, Debentures, etc.)
- Interests under wills
- Other property, as per List "H"
The names to be arranged in alphabetical order and numbered consecutively.
|No.||Name of creditor||Address||Amount of Claim|
|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|
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|
Contingent or Other Liabilities
Give particulars of claims not set out in List "B", or "C".
|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|
|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|
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.|
Real Property or Immovable Owned by Bankrupt
|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|
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.
|Nature of Property||Location||Details of property||Original cost||Estimated to produce|
|(b) Trade fixtures, etc.|
|(c) Cash in Financial Institution (name) (address)|
|(d) Cash on hand|
|(f) Machinery, equipment and plant|
|(h) Life insurance policies, RRSPs, etc.|
|(j) Interests under wills, etc.|
|(m) Other property (state particulars)|
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.
This form may not be completed online. It is provided here for reference purposes only.
The HTML version of this Form is not the official version. In the event of an inconsistency between the HTML and PDF versions of this Form, the PDF version prevails. Users are required to exercise due diligence with respect to the HTML version.
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