Form 79 — Statement of Affairs (Non-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)

Assets
Type of assets Description (Provide details) Estimated Dollar Value Exempt Property Secured Amount/ Liens Estimated net realizable dollar valueFootnote *
Yes No

Footnotes

  1. * For a summary administration, indicate value net of the direct realization costs referred to in Rule 128(1) of the BIA (back to footnote reference 1)
1. Cash on hand            
2. Furniture            
3. Personal effects            
4. Cash-surrender value of life insurance policies, RRSPs, etc.            
5. Securities            
6. Real Property or Immovable House            
Cottage            
Land            
7. Motor vehicle Automobile            
Motorcycle            
Snowmobile            
Other            
8. Recreational equipment            
9. Estimated Tax refund            
10. Other Assets            
TOTAL          
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            
2            
3            
4            
5            
6            
7            
8            
9            
10            
11            
12            
13            
14            
15            
16            
17            
18            
19            
20            
TOTAL Unsecured        
Secured        
Preferred        
TOTAL    
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 / Space to insert month / Space to insert day of month
YYYY / MM / DD
  Gender : F Select if gender is female M Select if gender is male  
2. Also known as:
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 of event for married person Space to insert year of event for married person
Married		 Space to insert month of event for single person Space to insert year of event for single person
Single
Space to insert month of event for widowed person Space to insert year of event for widowed person
Widowed		 Space to insert month of event for separated person Space to insert year of event for separated person
Separated
Space to insert month of event for divorced person Space to insert year of event for divorced person
Divorced		 Space to insert month of event for common-law partner Space to insert year of event for common-law partner
Common-law partner
5. Full name of spouse or common-law partner:
6. Name of present employer: Occupation (Bankrupt):
7A. Number of persons in household family unit, including bankrupt:
7B. Number of persons 17 years of age or less:
8. Have you operated a business within the last five years? Yes No (If yes) Name, type and period of operation:
First line - If Yes, insert name
Second line - If Yes, insert type
Third line - If Yes, insert period of operation
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 No
9B. Made payments in excess of the regular payments to creditors? Yes No
9C. Had any property seized by a creditor? Yes No
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 No
10B. Made any gifts to relatives or others in excess of $500? Yes No
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.

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