Form 78—Statement of Affairs (Business Bankruptcy/Proposal)

For persons to which the 2009 amendments apply

PDF version

Form 78

68.3 KB, 1 page

(Subsection 49(2) and Paragraph 158(d) of the Act / Subsections 50(2) and 62(1) of the Act)


(Title Form 1)

Checkbox for original Original Checkbox for amended Amended

To the bankrupt/debtor:

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 / date of filing your proposal (or, if applicable, notice of intention) on the Space to insert day day of Space to insert month Space to insert year. When completed, this form and the applicable attachments will constitute your Statement of Affairs and must be verified by oath or solemn declaration.

Liabilities
(as stated and estimated by bankrupt/debtor)
empty cell Amounts
1. Unsecured creditors as per list "A" $Space to insert amount for unsecured creditors as per list "A"
2. Secured creditors as per list "B" $Space to insert amount for secured creditors as per list "B"
3. Preferred creditors as per list "C" $Space to insert amount for preferred creditors as per list "C"
4. Contingent, trust claims or other liabilities as per list "D"
estimated to be reclaimable for
$Space to enter amount for contingent, trust claims or other liabilities as per list "D" estimated to be reclaimable
Total liabilities $Space to insert total amount
Surplus $Space to insert surplus amount
Assets
(as stated and estimated by bankrupt/debtor)
empty cell Amounts
1. Inventory $Space to insert amount of inventory
2. Trade fixtures, etc. $Space to insert amount for trade fixtures, etc.
3. Accounts receivable and other receivables as per list "E"  
Good $Space to enter amount for goods  
Doubtful $Space to insert amount for doubtful  
Bad $Space to insert amount for bad  
Estimated to produce $Space to insert estimated to produce amount $Space to enter total amount for accounts receivable and other receivable as per list "E"
4. Bills of exchange, promissory note, etc. as per list "F" $Space to insert amount for bills of exchange, promissory note, etc. as per list "F"
5. Deposits in financial institutions $Space to insert amount for deposits in financial institution
6. Cash $Space to insert cash amount
7. Livestock $Space to insert amount for livestock
8. Machinery, equipment and plant $Space to insert amount for machinery, equipment and plant
9. Real property or immovables as per list "G" $Space to insert amount for real property or immovables as per list "G"
10. Furniture $Space to insert amount for furniture
11. RRSPs, RRIFs, life insurance, etc. $Space to insert amount for RRSPs, RRIFs, life insurance, etc.
12. Securities (shares, bonds, debentures, etc.) $Space to insert amount for securities (shares, bonds, debentures, etc.)
13. Interests under wills $Space to insert amount for interests under wills
14. Vehicles $Space to insert amount for vehicles
15. Other property as per list "H"  
$Space to insert amount for other property as per list "H"  
$Space to insert amount for additional other property as per list "H" $Space to insert total amount for other property as per list "H"
If bankrupt/debtor 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
Balance subscribed and unpaid $Space to insert balance subscribed and unpaid
Estimated to produce $Space to insert estimated to produce amount
Total assets $Space to insert total assets amount
Deficiency $Space to insert amount of deficiency

I,Space to insert name, of the Space to insert type of community (city, town or village) of Space to insert name of city, town or village in the Province of Space to insert province, 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 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 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 province,
on this Space to insert day day of Space to insert month Space to insert year.

Space to insert signature of the Commissioner of Oaths
Commissioner of Oaths
for the Province of Space to insert name of province.

Space to insert signature of bankrupt/debtor
Signature of bankrupt/debtor

List "A"

Unsecured Creditors

Names to be arranged in alphabetical order and numbered consecutively.

List "A"
No. Name of creditor Address Amount of claim
       
       
Space to insert signature of bankrupt/debtor
Bankrupt/Debtor
Space to insert date
date

List "B"

Secured Creditors

List "B"
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 signature of bankrupt/debtor
Bankrupt/Debtor
Space to insert date
date

List "C"

Preferred Creditors for Wages, Rent, etc.

List "C"
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 signature of bankrupt/debtor
Bankrupt/Debtor
Space to insert date
date

List "D"

Contingent or Other Liabilities

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

List "D"
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 signature of bankrupt/debtor
Bankrupt/Debtor
Space to insert date
date

List "E"

Debts Due to the Bankrupt/Debtor

List "E"
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 signature of bankrupt/debtor
Bankrupt/Debtor
Space to insert date
date

List "F"

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

List "F"
No. Name of all promissory, acceptors, endorsers, mortgagors and guarantors Address Occupation Amount of bill or note, etc. Date when due Estimated to produce Particulars of any property held as security for payment of bill or note, etc.
               
               
Space to insert signature of bankrupt/debtor
Bankrupt/Debtor
Space to insert date
date

List "G"

Real Property or Immovables Owned by Bankrupt/Debtor

List "G"
Description of property Nature of bankrupt's/
debtor'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 signature of bankrupt/debtor
Bankrupt/Debtor
Space to insert date
date

List "H"

Property

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

Full Statement of Property

List "H"
Nature of property Location Details of property Original cost Estimated to produce
(a) Stock-in-trade        
(b) Trade fixtures, etc.        
(c) Cash in financial institutions (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 signature of  bankrupt/debtor
Bankrupt/Debtor
Space to insert date
Date

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.

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