Form 79—Statement of Affairs (Non-Business Bankruptcy)

For persons to which the 2009 amendments do not apply

PDF version

Form 79

35 KB, 4 pages

(Paragraph 158(d) of the Act)


(Title Form 1)

Assets
Type of assets Description (Provide details) Estimated Dollar Value Exempt Property Secured Amount/ Liens Estimated net realizable dollar valueFootnote a
Yes No
1. Cash on hand empty cell empty cell empty cell empty cell empty cell empty cell
2. Furniture empty cell empty cell empty cell empty cell empty cell empty cell
3. Personal effects empty cell empty cell empty cell empty cell empty cell empty cell
4. Cash-surrender value of life insurance policies, RRSPs, etc. empty cell empty cell empty cell empty cell empty cell empty cell
5. Securities empty cell empty cell empty cell empty cell empty cell empty cell
6. Real Property or Immovable House empty cell empty cell empty cell empty cell empty cell empty cell
Cottage empty cell empty cell empty cell empty cell empty cell empty cell
Land empty cell empty cell empty cell empty cell empty cell empty cell
7. Motor vehicle Automobile empty cell empty cell empty cell empty cell empty cell empty cell
Motorcycle empty cell empty cell empty cell empty cell empty cell empty cell
Snowmobile empty cell empty cell empty cell empty cell empty cell empty cell
Other empty cell empty cell empty cell empty cell empty cell empty cell
8. Recreational equipment empty cell empty cell empty cell empty cell empty cell empty cell
9. Estimated Tax refund empty cell empty cell empty cell empty cell empty cell empty cell
10. Other Assets empty cell empty cell empty cell empty cell empty cell empty cell
TOTAL empty cell empty cell empty cell empty cell empty cell
Space to insert date (Assets)
Date
Space to insert bankrupt's signature (Assets)
Bankrupt

Liabilities type code (LTC)

  1. Real Property or Immovable Mortgage or Hypothec
  2. Bank Loans (except real property mortgage)
  3. Finance Company Loans
  4. Credit Cards Bank/Trust Companies Issuers
  5. Credit Cards Other Issuers
  6. Taxes Federal/Provincial/Municipal
  7. Student Loans
  8. Loans from Individuals
  9. Other
Liabilities and Amounts
Creditor Address including postal code Account No. Amount of debt Enter LTC
Unsecured Secured Preferred
1 empty cell empty cell empty cell empty cell empty cell empty cell
2 empty cell empty cell empty cell empty cell empty cell empty cell
3 empty cell empty cell empty cell empty cell empty cell empty cell
4 empty cell empty cell empty cell empty cell empty cell empty cell
5 empty cell empty cell empty cell empty cell empty cell empty cell
6 empty cell empty cell empty cell empty cell empty cell empty cell
7 empty cell empty cell empty cell empty cell empty cell empty cell
8 empty cell empty cell empty cell empty cell empty cell empty cell
9 empty cell empty cell empty cell empty cell empty cell empty cell
10 empty cell empty cell empty cell empty cell empty cell empty cell
11 empty cell empty cell empty cell empty cell empty cell empty cell
12 empty cell empty cell empty cell empty cell empty cell empty cell
13 empty cell empty cell empty cell empty cell empty cell empty cell
14 empty cell empty cell empty cell empty cell empty cell empty cell
15 empty cell empty cell empty cell empty cell empty cell empty cell
16 empty cell empty cell empty cell empty cell empty cell empty cell
17 empty cell empty cell empty cell empty cell empty cell empty cell
18 empty cell empty cell empty cell empty cell empty cell empty cell
19 empty cell empty cell empty cell empty cell empty cell empty cell
20 empty cell empty cell empty cell empty cell empty cell empty cell
TOTAL Unsecured empty cell empty cell empty cell empty cell
Secured empty cell empty cell empty cell empty cell
Preferred empty cell empty cell empty cell empty cell
TOTAL empty cell empty cell
Space to insert date (Liabilities and amounts)
Date
Space to insert bankrupt's signature (Liabilities and amounts)
Bankrupt

Information relating to the affairs of the bankrupt

1. Family name:
Given names:
Date of birth:
Space to insert year of birth / Space to insert month of birth / Space to insert day of birth
YYYY / MM / DD
 
Gender : F Select if gender is female M Select if gender is male
 
2. Also known as: Space to insert pseudonym or alias name
3. Complete address, including postal code
Space to insert first line of complete address, including postal code
Space to insert second line of complete address, including postal code
4. Marital status:
(Specify month and year of event if it occurred in the last five years)
Space to insert month when got married Space to insert year when got marriedMarried
Space to insert month when single again Space to insert year when single again Single
Space to insert month when got widowed Space to insert year when got widowed Widowed
Space to insert month when got separated Space to insert year when got separatedSeparated
Space to insert month when got divorced Space to insert year when got divorced Divorced
Space to insert month when began common law status Space to insert year when began common law status Common-law partner
5. Full name of spouse or common-law partner: Space to insert full name of spouse or common-law partner
6. Name of present employer: Space to insert name of present employer
Occupation (Bankrupt): Space to insert occupation
7A. Number of persons in household family unit, including bankrupt: Space to insert Number of persons in household family unit, including bankrupt
7B. Number of persons 17 years of age or less: Space to insert number of persons 17 years of age or less
8. Have you operated a business within the last five years?
Yes
check here if you have operated a business within the last five years
No
check here if you have not operated a business within the last five years
(If yes) Name, type and period of operation:
First space to insert: name, type and period of operation if answer is positive
Second space to insert: name, type and period of operation if answer is positive
B. WITHIN THE 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?
Yes check here if you have operated a business within the last five years
No check here if you have not operated a business within the last five years
9B. Made payments in excess of the regular payments to creditors?
Yes check here if you have made payments in excess of the regular payments to creditors
No check here if you have not made payments in excess of the regular payments to creditors
9C. Had any property seized by a creditor?
Yes check here if you had any property seized by a creditor
No check here if no property have been seized by a creditor
C- WITHIN FIVE YEARS PRIOR TO THE DATE OF THE INITIAL BANKRUPTCY EVENT, WHILE YOU KNEW YOURSELF TO BE INSOLVENT, HAVE YOU, EITHER IN CANADA OR ELSEWHERE:
10A. Sold or disposed of any property?
Yes check here if you have sold or disposed of any property
No check here if you have not sold or disposed of any property
10B. Made any gifts to relatives or others in excess of $500?
Yes check here if you have made any gifts to relatives or others in excess of $500
No check here if you have not made any gifts to relatives or others in excess of $500
Space to insert date (Information relating to the affairs of the bankrupt)
Date
Space to insert bankrupt (Information relating to the affairs of the bankrupt)
Bankrupt

D. Budget information: Attach Form 65 to this Form.

11A. Have you ever made a proposal under the Bankruptcy and Insolvency Act?
Yes Select if you have made a proposal under the Bankruptcy and Insolvency Act No Select if you have not made a proposal under the Bankruptcy and Insolvency Act

11B. Have you been bankrupt before, either in Canada or elsewhere?
Yes Select if you have been bankrupt before, either in Canada or elsewhere No Select if you have not been bankrupt before, either in Canada or elsewhere

(If you answered 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.)
Space to insert first line for details for all insolvency proceedings
Space to insert second line for details for all insolvency proceedings
Space to insert third line for details for all insolvency proceedings

12. Do you expect to receive any sums of money which are not related to your normal income, or any other property within the next 12 months?
Yes Select if you expect to receive any sums of money which are not related to your normal income, or any other property within the next 12 months No Select if you don't expect to receive any sums of money which are not related to your normal income, or any other property within the next 12 months

13. If you answered Yes to any of questions 9, 10 and 12, provide details:
1. Space to insert details if you have answered yes to any of questions 9, 10 and 12
2. Space to insert details if you have answered yes to any of questions 9, 10 and 12
3. Space to insert details if you have answered yes to any of questions 9, 10 and 12

14. Give reasons for your financial difficulties:
1. Space to insert reasons for your financial difficulties
2. Space to insert reasons for your financial difficulties
3. Space to insert reasons for your financial difficulties

I, Space to insert bankrupt's name, of the Space to insert company or organization of Space to insert city of company, in the Province of Space to insert province, do swear (or solemnly declare) that this statement is, 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 discloses all property and transactions of every description that is or was in my possession or that may devolve on me in accordance with section 67 of the Bankruptcy and Insolvency Act.

Sworn (or Solemnly declared)

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

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
Bankrupt

for the Province of Space to insert province.

Note:

If a copy of this Form 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.

Important Notices

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.

Date modified: