For persons to which the 2009 amendments do not apply
PDF version
35 KB, 4 pages
(Paragraph 158(d) of the Act)
(Title Form 1)
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 | ||
Date
Bankrupt
Liabilities type code (LTC)
- Real Property or Immovable Mortgage or Hypothec
- Bank Loans (except real property mortgage)
- Finance Company Loans
- Credit Cards Bank/Trust Companies Issuers
- Credit Cards Other Issuers
- Taxes Federal/Provincial/Municipal
- Student Loans
- Loans from Individuals
- Other
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 |
Date
Bankrupt
Information relating to the affairs of the bankrupt
YYYY / MM / DD
(Specify month and year of event if it occurred in the last five years)
Date
Bankrupt
D. Budget information: Attach Form 65 to this Form.
11A. Have you ever made a proposal under the Bankruptcy and Insolvency Act?
Yes No
11B. Have you been bankrupt before, either in Canada or elsewhere?
Yes No
(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.)
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 No
13. If you answered Yes to any of questions 9, 10 and 12, provide details:
14. Give reasons for your financial difficulties:
I, , of the of , in the Province of , 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 day of 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 (city, town or village)
the Province of ,
on this day of .
Commissioner of Oaths
Bankrupt
for the Province of .
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.