Unclaimed Dividends Claim Form—Individual Creditor

Estate name or estate number: Form Field - line
(Name or number appearing in the Unclaimed Dividends Database)

Individual Creditor Information

Name: Space to insert name
Current address: Space to insert current address
City: Space to insert city
Province: Space to insert province
Postal code: Space to insert postal code
Phone: Space to insert phone number ext. Space to insert extension (daytime) Space to insert evening phone number (evening)
Email: Space to insert email address

If you are an authorized third party submitting a claim on behalf of the individual creditor, provide the following information:

Name: Space to insert name of authorized third party
Current address: Space to insert address of authorized third party
City: Space to insert city of authorized third party
Province: Space to insert province of authorized third party
Postal code: Space to insert postal code of authorized third party
Phone: Space to insert phone number of authorized third party ext. Space to insert extension of authorized third party (daytime) Space to insert evening phone number of authorized third party (evening)
Email: Space to insert email address of authorized third party

Checkbox for attached Power of Attorney Attached Power of Attorney or last will and testament establishing that you have the authority to submit this claim on behalf of the aforementioned individual creditor (original or true certified copy).

Banking Information

If you would like to receive a direct deposit instead of a cheque, provide the following information:

Name of financial institution: Space to insert name of financial insitution
Address of financial institution: Space to insert address of financial institutiony
Financial institution no. (3 digits): Space to insert financial institution number
Branch transit no. (5 digits): Space to insert branch transit number
Name(s) of account holder(s): Space to insert name(s) of account holder(s)
Bank account no. : Space to insert bank account number
SWIFT code (international payments only): Space to insert SWIFT code
IBAN no. (international payments only): Space to insert IBAN number

A void cheque OR a copy of a blank cheque must be attached to this form.

Consent

I, the undersigned, consent to the Receiver General for Canada issuing my payments as indicated above, by direct deposit, to my bank account. I, the undersigned, have read the Privacy Notice and consent to the collection, use and disclosure of my personal information as outlined in the notice. To ensure prompt payment(s), I will notify the Receiver General for Canada of any changes to my banking information. I, the undersigned, confirm that all information provided above is correct.

Privacy Notice
Your personal information is collected pursuant to the Financial Administration Act, ss. 17(1) and 35(2). The information is used and disclosed to the relevant federal program(s) and to your financial institution for direct deposit purposes. Direct deposit payments cannot be made without providing the information requested on this form. Personal information is protected in accordance with the provisions of the Privacy Act. Under the Act, individuals and businesses have a right to request access to and correct their personal information, if erroneous or incomplete. Personal information collected from this form is stored in the following Standard Personal Information Bank—IC-PSU-931 (Accounts Payable). For questions or comments regarding this privacy notice or for additional information about the administration of the Privacy Act at Industry Canada, please communicate with the Information and Privacy Rights Administration office at 613-952-2088. For more information on privacy issues and the Privacy Act in general, please consult with the Office of the Privacy Commissioner at 1-800-282-1376.

Signature of Applicant: Space to insert signature of applicant
Name of Applicant: Space to enter name of applicant
Date (YYYY-MM-DD): Space to insert date


Mailing the form

Forward the completed form, an affidavit and a cheque or money order for $30 (payable to the Receiver General for Canada) to:

Office of the Superintendent of Bankruptcy Canada (Headquarters)
Attention: Trust Fund Administrator
235 Queen St.
Ottawa, Ontario K1A 0H5

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