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

PDF version
(68 KB, 1 page)

PDF readers

Coming into force September 18, 2009
(Subsection 49(2) and Paragraph 158(d) of the Act / Subsections 50(2) and 62(1) of the Act)

This form may not be completed online. It is provided here for reference purposes only.

(Title Form 1)

Checkbox Original Checkbox 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 Line day of Line Line. 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)
1. Unsecured creditors as per list "A" $Line
2. Secured creditors as per list "B" $Line
3. Preferred creditors as per list "C" $Line
4. Contingent, trust claims or other liabilities as per list "D" estimated to be reclaimable for $Line
Total liabilities $Line
Surplus $Line


Assets
(as stated and estimated by bankrupt/debtor)
1. Inventory $Line
2. Trade fixtures, etc. $Line
3. Accounts receivable and other receivables as per list "E"  
Good $Line  
Doubtful $Line  
Bad $Line  
Estimated to produce $Line $Line
4. Bills of exchange, promissory note, etc. as per list "F" $Line
5. Deposits in financial institutions $Line
6. Cash $Line
7. Livestock $Line
8. Machinery, equipment and plant $Line
9. Real property or immovables as per list "G" $Line
10. Furniture $Line
11. RRSPs, RRIFs, life insurance, etc. $Line
12. Securities (shares, bonds, debentures, etc.) $Line
13. Interests under wills $Line
14. Vehicles $Line
15. Other property as per list "H"  
$Line  
$Line $Line
If bankrupt/debtor is a corporation, add:  
Amount of subscribed capital $Line
Amount paid on capital $Line
Balance subscribed and unpaid $Line
Estimated to produce $Line
Total assets $Line
Deficiency $Line

I, Line, of the Line of Line in the Province of Line, 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 Line day of Line Line 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 Line (city, town or village),
in the Province of Line,
on this Line day of Line Line.

Line
Commissioner of Oaths
for the Province of Line.

Line
Signature of bankrupt/debtor

List "A"

Unsecured Creditors

Names to be arranged in alphabetical order and numbered consecutively.

No. Name of creditor Address Amount of claim
       
       
Line
Bankrupt/Debtor
Line
date

List "B"

Secured Creditors

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
                 
                 
Line
Bankrupt/Debtor
Line
date

List "C"

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
               
               
Line
Bankrupt/Debtor
Line
date

List "D"

Contingent or Other Liabilities

Give particulars of claims not set out in lists "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
             
             
Line
Bankrupt/Debtor
Line
date

List "E"

Debts Due to the Bankrupt/Debtor

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
                 
                 
Line
Bankrupt/Debtor
Line
date

List "F"

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

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.
               
               
Line
Bankrupt/Debtor
Line
date

List "G"

Real Property or Immovables Owned by Bankrupt/Debtor

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
           
           
Line
Bankrupt/Debtor
Line
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

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)        
Line
Bankrupt/Debtor
Line
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 notice: The XHTML version of this Form is not the official version. In the event of an inconsistency between the XHTML and PDF versions of this Form, the PDF version prevails. Users are required to exercise due diligence with respect to the XHTML version.