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

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Statement of Affairs (Non-Business Bankruptcy/Proposal)

(Subsections 49(2) and Paragraph 158(d) of the Act / Subsections 50(2) and 62(1) and Paragraph 66.13(2)(d) of the Act)

(Title of Asset)

Original Amended

Assets
Type of Assets		Description (provide details)	Estimated Dollar Value	Exempt Property		Secured Amount / Liens	Estimated Net Realizable Dollar Value*
Type of Assets		Description (provide details)	Estimated Dollar Value	Yes	No	Secured Amount / Liens	Estimated Net Realizable Dollar Value*
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 immovables	House
	Cottage
	Land
7. Motor vehicle	Automobile
	Motorcycle
	Snowmobile
	Other
8. Recreational equipment
9. Estimated tax refund
10. Other assets
Total

Date

Bankrupt/Debtor

* For a summary administration, indicate value net of the direct realization costs referred to in Rule 128(1) of the Bankruptcy and Insolvency General Rules. Back to text

Liabilities type code (LTC)

Real property or immovable mortgage or hypothec
Bank loans (except real property mortgage)
Finance company loans
Credit cards - bank/trust company issuers
Credit cards - other issuers
Taxes - federal/provincial/municipal
Student loans
Loans from individuals
Other

**Liabilities**
Creditor	Address (including postal code)	Account No.	Amount of Debt			Enter LTC
Creditor	Address (including postal code)	Account No.	Unsecured	Secured	Preferred	Enter LTC
1
2
3
4
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Pledged Assets: (provide details)	Total	Unsecured
	Total	Secured
	Total	Preferred
Total

Date

Bankrupt/Debtor

Information relating to the affairs of the bankrupt/debtor

A. Personal Data

1. Family name:

Given names:

Gender

Date of birth

MM / DD / YYYY

2. Also known as:

3. Complete address, including postal code:

4. Marital status:
(specify month and year of event if it occurred in the last five years)

Married

Widowed

Divorced

Single

Separated

Common-law partner

5. Full name of spouse or common-law partner:

6. Name of present employer:

Occupation (bankrupt/debtor):

7A. Number of persons in household family unit, including bankrupt/debtor:

7B. Number of persons 17 years of age or younger:

8. Have you operated a business within the last five years?

Yes

(If yes) Name, type and 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

9B. Made payments in excess of the regular payments to creditors?

Yes

9C. Had any property seized by a creditor?

Yes

C. Within the five years prior to the date of the initial bankruptcy event, have you, either in Canada or elsewhere:

10A. Sold or disposed of any property?

Yes

10B. Made any gifts to relatives or others in excess of $500?

Yes

Date

Bankrupt/Debtor

D. Budget information: Attach Form 65 to this form

11A. Have you ever made a proposal under the Bankruptcy and Insolvency Act?
Yes

11B. Have you been bankrupt before in Canada?
Yes

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, whether the proposal was successful; (d) date on which Certificate of Full Performance or Discharge was obtained.
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12. Do you expect to receive any sums of money that are not related to your normal income, or any other property within the next 12 months?
Yes

13. If you answered yes to any of questions 9, 10 or 12, provide details:
space 1 to insert details of questions 9, 10 or 12

space 2 to insert details of questions 9, 10 or 12

space 3 to insert details of questions 9, 10 or 12

space 4 to insert details of questions 9, 10 or 12

14. Give reasons for your financial difficulties:

space 1 to reasons for your financial difficulties
space 2 to insert reasons for your financial difficulties
space 3 to insert reasons for your financial difficulties
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I, space to insert name of debtor/bankrupt of space to insert name of city, town or village in the province of space to insert name of 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 space to insert date 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 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),
in the Province of space to insert name of province , on this space to insert day day of space to insert month space to insert year .

Commissioner of Oaths

Bankrupt/Debtor

for the Province of space to insert name of 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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