Unclaimed Dividends Claim Form—Business Creditor

Estate name or estate number: Space to enter estate name, estate number or claim number
(Note: Name or number appearing in the Unclaimed Dividends Database)

Business Creditor Information

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

Status of the company: Checkbox for active company Active Checkbox for dissolved company Dissolved

Checkbox for attached Certificate of Compliance Attached current Certificate of Compliance or equivalent

Legal Representative of Business Creditor

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

Indicate relationship to business creditor:

Checkbox for attached Letter of Authority Attached Letter of Authority, or equivalent documentation, establishing that you have the authority to submit this claim on behalf of the aforementioned business creditor.

If you are an authorized third party making a claim on behalf of the business 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 business creditor.

In cases where the business creditor is now operating under a different name, provide the required information as applicable:

Provide the required information as applicable:

  • The business creditor underwent a name change
    • Checkbox for attached copy of the Change of Name Registration Certificate Attached copy of the Change of Name Registration Certificate or equivalent documentation (original or true certified copy)
  • The business creditor has gone through a change of ownership
    • Checkbox for attached proff of amalgation Attached proof of amalgamation, or proof that the assets (including receivables and debts) were acquired by the successor (original or true certified copy)
  • The business creditor operates under different names, one being the name appearing in the Unclaimed Dividends Database
    • Checkbox for attached printout of the company registry Attached printout of the company registry, or equivalent documentation, demonstrating that the company also operates under the name appearing in the Unclaimed Dividends Database (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, the required documentation, 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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