Estate Information Summary (Coming into Force Date: December 16, 2011)

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Check Original Check Amended

I – Complete the following in all cases
Proceeding
Check Assignment
Check Referral
Check Bankruptcy order
Check Proposal
Check Individual Check Corporation Check Income Trust
Estate Name
Occupation
Language
Check EnglishCheck FrenchCheck Other, specify
Ind. date of birth
D
M
Y
 
 
 
Previous or current BIA proceeding?

Check Yes Check No
If yes, enter estate number(s)
Indicate if previous bankruptcy
Check Yes Check No
If yes, how many?
Address (Street No. and Apt. No.)
lines
Indicate if receivership
Check Yes Check No
D
M
Y
 
 
 
City
Province
Postal code
 
 
 
 
 
 
Home telephone No.
( 
 
 )
 
 
-
 
 
 
 
Work telephone No.
( 
 
 )
 
 
 -
 
 
 
 
Consumer debts only?
Check Yes Check No
% 
of the total debt is business
The debtor resides or has carried on business at the above address since:
D
M
Y
 
 
 
Highest level of education completed by joint bankrupt/debtor: (for statistical purposes only)
Check
0-8 years
Check
some high school
Check
high school graduate
Check
some post-
secondary
Check
post-secondary certificate or diploma
Check
university degree
Check
refuses to answer or does not know
Joint Estate Name
Occupation
Language
Check English Check French Check Other specify
Ind. date of birth
D
M
Y
 
 
 
Previous or current BIA proceeding?
Check Yes Check No
If yes, enter estate number(s)
Indicate if previous bankruptcy
Check Yes Check No
If yes, how many?
Highest level of education completed by joint bankrupt/debtor: (for statistical purposes only)
Check
0-8 years
Check
some high school
Check
high school graduate
Check
some post-
secondary
Check
post-secondary certificate or diploma
Check
university degree
Check
refuses to answer or does not know
 
Indicate if receivership
Check Yes
Check No
D
M
y
 
 
 
II – Complete the following if the debtor has guaranteed the debts of another person
Check N/A
The debtor is the guarantor of
Check Business debts Check Consumer debts Check Other specify
Is the person bankrupt?
Name of persons whose debts are guaranteed
Amount guaranteed
Name of business if business debts
Yes
No
 
 
 
 
 
III – Complete the following if the debtor was previously or is presently in business
Check N/A
Trade name(s) if different from the estate name
Place of business
Nature of business
Corporation, partnership or sole proprietorship (specify)
 
 
 
 
Names of the partners if a partnership:
During the past 12 months, what was the maximum number of employees that you employed?
How long have you been in operation under this current legal name?
IV – Complete the following if the debtor is a corporation, including an income trust
Are the corporation's shares or units publicly traded?
Check Yes Check No
Federal Charter?
Check Yes Charter Number Check No
Names of the Corporation's officers:
Name of person to be examined
Title
Telephone No.
( 
 
 )
 
 
-
 
 
 
 
Address (Street No. and Apt. No.)
City
Province
Postal code
 
 
 
 
 
 
Language Check English Check French Check Other specify
During the past 12 months, what was the maximum number of employees that you employed?
How long have you been in operation under this current legal name?
V – To be completed when filing a consumer proposal or amended consumer proposal
Terms of the Consumer Proposal: (choose one only of A, B, C or D)
A)
 
(number) payments of
$ 
for a total of
$ 
B)
A lump sum payment of
$ 
C)
A lump sum $ payment of
$ 
+
 
(number) payments of
$ 
for a combined total of
$ 
D) Other: please describe terms below
Anticipated Completion Date of Consumer Proposal:
D
M
Y
 
 
 
Amount outstanding on mortgage or hypothec on principal residence
$ 
VI – To be completed and signed by the trustee in all cases
Creditor's Meeting Suggested Time and Place
D
M
Y
 
 
 
Time
Location
Trustee Appointment
Name & Licence number of the Trustee or, if a Corporate Trustee, the name &
licence number of the person responsible for the administration of the estate.
Licence number
 
 
 
 
A possible conflict of interest situation exists Check Yes Check No
If yes, explain:
Indemnification: Check N/A Check Deposit Check Guarantee Name of depositor or guarantor
Amount or extent of indemnity
Check Trustee absent when file submitted Amended summary to follow
Signature of Trustee
VII – Official receiver use only
Note: quote this number in all future correspondence
No.
 
 
-
 
 
 
 
 
 
-
 
 
Administration
Check Summary Check Ordinary
Date of filing
D
M
Y
 
 
 
Type
Industry
 
 
District
 
 
Division
 
 
 
Court No.
 
 
 
 
 
 
 
 
 
 
 
Licence No. of appointed Trustee
Check As above Check Other
Resp. O.R.
Assets
 
 
 
 
 
 
 
 
 
 
Liabilities
 
 
 
 
 
 
 
 
 
 
Security
 
 
 
 
 
 
 
 
 
 
Creditor's Meeting
Check As above Check Or
Date
D
M
Y
 
 
 
Time
 
 
 
 
 
 
Location
Chairperson
Check O.R. Check Trustee
Debtor Examination
Check Yes Check No
Date
D
M
Y
 
 
 
Time
 
 
 
 
 
 
Location
 
Official Receiver Comments
Note to file
Check A Check B Check C
Official Receiver's Initials
Data Processing Initials
Document Production Initials