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

For persons to which the 2009 amendments apply

PDF and Word versions

Form 79 (PDF)

122 KB, 4 pages

Form 79 (Word)

152 KB, 4 pages

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 Form 1)

(Title of Asset)

Checkbox: Original Original Checkbox: Amended Amended

Assets
Type of Assets Description (provide details) Estimated Dollar Value Exempt Property Secured Amount / Liens Estimated Net Realizable Dollar ValueFootnote *
Yes No
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
space to insert date
Date
space to insert Bankrupt/Debtor
Bankrupt/Debtor

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 company issuers
  5. Credit cards - other issuers
  6. Taxes - federal/provincial/municipal
  7. Student loans
  8. Loans from individuals
  9. Other
Liabilities
Creditor Address (including postal code) Account No. Amount of Debt Enter LTC
Unsecured Secured Preferred
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
space to insert date
Date
space to insert Bankrupt/Debtor
Bankrupt/Debtor

A. Information relating to the affairs of the bankrupt/debtor

Information relating to the affairs of the bankrupt/debtor
1. Family name: Given names: 2. Also known as:
  Gender
Checkbox: Female F Checkbox: Male M
Date of birth:
space to insert year of birth/space to insert month of birth/space to insert day of birth
 YYYYMMDD
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)
space to insert month of marriagespace to insert year of marriage
Married
space to insert month of single lifespace to insert year of  single life Single
Widowed space to insert month of separationspace to insert year of  separationSeparated
space to insert month of divorcespace to insert year of divorce
Divorced
space to insert  Common-law partnershipspace to insert year of   Common-law partnershipCommon-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 No (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:

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

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 No
10B. Made any gifts to relatives or others in excess of $500? Yes No
space to insert date
Date
space to insert Bankrupt/Debtor
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 Checkbox: Yes, Have you ever made a proposal under the Bankruptcy and Insolvency Act? No Checkbox: No, Have you ever made a proposal under the Bankruptcy and Insolvency Act?
11B. Have you been bankrupt before in Canada?
Yes Checkbox: Yes, Have you been bankrupt before in Canada? No Checkbox: No, Have you been bankrupt before in Canada?
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.
space 1 to insert details for all insolvency proceedings
space 2 to insert details for all insolvency proceedings
space 3 to insert details for all insolvency proceedings
space 4 to insert details for all insolvency proceedings
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 Checkbox: Yes, 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? No Checkbox: No, 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?
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
space 4 to insert reasons for your financial difficulties

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.

space to insert name  of Commissioner of Oaths
Commissioner of Oaths
space to insert name of bankrupt/debtor
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.

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.

Date modified: