Business affidavit form

In the matter of space to insert estate number, estate name or claim number (insert estate number(s) or estate name(s) from the Unclaimed Funds Database) for unclaimed dividends held by the Receiver General, I swear or say under penalty of perjury:

  1. That space to insert the company's name (insert the company’s name) is entitled to the unclaimed dividends specified in the claim attached hereto;
  2. That I, space to insert the name of the legal representative (insert the name of the legal representative), am the legal representative of the business creditor to whom the funds held are payable;
  3. That I have knowledge of the circumstances connected with this claim;
  4. That I have reason to believe that the Receiver General for Canada holds unclaimed dividends to which (insert the company’s name) is entitled in the amount of $space to insert estate unclaimed dividend or unclaimed dividends (insert amount);
  5. That space to insert the company's name (insert the company’s name) has not been reimbursed by a third party and the amounts are still owed;
  6. That space to insert the company's name(insert the company’s name) is entitled to request payment of the unclaimed dividends pursuant to subsection 154(1) of the Bankruptcy and Insolvency Act;
  7. That space to insert the company's name(insert the company’s name) claims the unclaimed dividends pursuant to subsection 154(2) of the Bankruptcy and Insolvency Act;
  8. That space to insert the company's name(insert the company’s name) agrees and undertakes to indemnify Her Majesty and her officers, officials, employees and agents if it is determined that the company is not entitled to the funds;
  9. That space to insert the company's name(insert the company’s name) has or had a place of business at (insert address from Unclaimed Funds Database); and
  10. That the content of the attached Claim Form and supporting documents is accurate and true.

Sworn before me in the city of space to insert city in the province of space to insert province this day of space to insert month, 20space to insert last two digits of year.

space to insert the name of the Commissioner of Oaths
Commissioner of Oaths

space to insert creditor or legal representative
Creditor or legal representative

space to insert print name or stamp
Print name or stamp

space to insert print name
Print name

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