Claim for Loss

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Canada Small Business Financing Act

Claim For Loss

Note: Please print. If necessary, provide additional information on an annex. (instructions attached)

8

 History of business, purpose for which the loan was made and other relevant information pertaining to the administration of the loan

9

  Replaced by a "Summary of Eligible Costs" worksheet, attached to the Claim for Loss form

Purchase of / Improvements to real property or immovables (owner)

$

%

$

Leasehold improvements (tenant) — New and existing

$

%

$

Equipment (including software)

$

%

$

CSBF fee financed

$

100%

$

Total Eligible

$

$

10

 Lender's loan
approval date

Year

Month

Day

11

 Date of first scheduled repayment of principal and/or interest

Year

Month

Day

12

 Date of first purchase or commitment by borrower for assets financed

Year

Month

Day

13

 Date of first loan disbursement

Year

Month

Day

14

 Total loan amount disbursed

$

Loan registration no.

1. Poor management skills
2. Inadequate equity capital
3. Adverse developments in the industry or economy
4. Personal problems of the principal
5. Unrealistic plans and projections
6. Difficulties with major suppliers or customers
7. Loss of key management
8. Fraudulent business activities
9. Excessive cash drain by owner
10. Other

1

Yes No

2

Yes No

Personal
Corporate

Yes No

Personal
Corporate

Yes No

Personal
Corporate

Yes No

Primary Additional

Primary Additional

19

 Realization Actions — describe realization measures undertaken or reasons not to pursue realization action for Lines 16, 17, & 18.

20

Date to which interest was paid by the borrower

Year

Month

Day

 

 

 

 

 

 

 

 

 

 

Interest Rate

Fixed

Floating

___________%

21

Date of next scheduled payment after the date in Line 20

Year

Month

Day

 

 

 

 

 

 

 

 

 

 

Interest Rate

Fixed

Floating

_________%

Loan registration no.

23

 Date of last payment on principal

Year

Month

Day

Principal outstanding amount of the loan

$

$

$

%

$

$

%

$

$

%

$

$

%

$

$

%

$

$

%

$

$

%

$

$

%

$

$

%

$

$

%

$

$

%

$

$

%

30

Amount of Loss After Realization and costs

= $

31

Interim claim
Less holdback (full amount of the compromise settlement or the full amount of the guarantee(s) or suretyship(s))

- $

32

For interim claims, Interim claim’s final proposed date of submission

Year

Month

Day

 

 

 

 

 

 

 

 

 

 

33

Amount of Loss (Excluding Interest)

= $

Forward to:
Industry Canada
Canada Small Business Financing Program
235 Queen Street, Ottawa, Ontario K1A 0H5

Information on the program and forms available at:
www.ic.gc.ca/csbfp

Instructions

1. Indicate the name, address and postal code of the lender who has responsibility for the loan account.
2. Enter the name, address and postal code to whom the payment should be forwarded (if different from Line 1) and the name of the person to whom payment should be directed.
3. Enter the transit number of the lender branch indicated in Line 1.
4. Enter the complete loan number and extension assigned to the loan by the lender.
5. Enter the loan registration number (6 digits) assigned under the Canada Small Business Financing Program.
6. Enter the borrower's name (as registered) and the most recent address and postal code.
7. Provide the operating name of the business, if different from the borrower's name.
8. Describe the history of the business and the purpose for which the loan was made. Indicate other relevant information pertaining to the administration of the loan such as transfer of loan between borrowers and/or lenders.
9. Indicate in the box if you are choosing to use the "Summary of Eligible Costs" worksheet instead of completing the table in Line 9. Please attach the worksheet to the Claim For Loss form. An electronic version of the "Summary of Eligible Costs" is available on the website.

   If you choose to use the table in Line 9 instead of using the Worksheet option above, please provide for each class of loan:

   • the eligible cost of the assets as substantiated by invoices, contracts and proofs of payment, etc. (listing should be provided);
   • the percentage of costs financed by CSBF;
   • the calculation of the eligible amount of the loan for each class.
10. Enter the date the loan was approved by an authorized representative of the lender.
11. Enter the date of the first scheduled repayment of principal and/or interest.
12. Enter the date of the first purchase or commitment by borrower for assets financed.
13. Enter the date the lender made the first loan disbursement.
14. Enter the total loan amount disbursed.
15. Indicate in the boxes the two principal reasons for the loan default using the codes indicated. If there is another reason for loan default enter the description.
16. Provide the full name of each borrower. If it is a partnership list both persons/corporations. Using the following codes, indicate which best describe the status of the borrower.
    1. Bankrupt
    2. Cannot be located
    3. Compromise settlement
    4. Liability extinguished
    5. Unable to pay
    6. Severe hardship
    7. Non-resident
    8. Further action not cost effective
    9. Some possibility of recovery
    10. Good possibility of recovery
    11. Consumer Proposal

    Indicate the estimated net worth of the borrower(s) at the date of claim for loss preparation using the following codes:

    1. Nil
    2. $1 - $10,000
    3. $10,001 - $50,000
    4. $50,001 - $100,000
    5. Over $100,000
    6. Not known

    Indicate if a judgement has been obtained. Use the Detail section (in Line 19 of this form) to briefly describe the current status of each borrower.

17. List the personal and corporate guarantee(s) or suretyship(s) obtained on the loan and list subsequent amendments. Using the status codes and the net worth codes (listed in Instruction 16), describe the current status and net worth of the guarantor(s) or surety(ies). Indicate if a judgement has been obtained where money is owed to the lender.

    Use the Detail section (in Line 19 of this form) to provide any other relevant information on the status of the guarantee(s) or suretyship(s).

18. List the asset security obtained on the loan and any subsequent amendments. Use the Detail section (in Line 19 of this form) to briefly describe the realization process with respect to the secured assets and the borrower.
19. Describe briefly the realization process with respect to the borrower(s), the guarantor(s) or suretyship(s) and the security as listed above in Instructions 16, 17, and 18. If applicable, explain the reason why no recovery actions were taken and any potential for additional recovery.
20. Enter the date to which interest was paid by the borrower and the interest rate in effect on that date.
21. Enter the date of the next scheduled interest payment pursuant to the loan document or any revision to the loan document. Enter the interest rate in effect on that date.
22. For loans approved under CSBFA, enter the date to which the lender has given the borrower to comply with a condition of the loan document. If the lender does not send a Notice of Default, enter the day after the final payment received from the borrower.
23. Enter the date of last payment on principal and the principal amount outstanding on the loan at this date.
24. Enter the total outstanding amount of all the borrower's loans, including the CSBFA loans, at the date indicated in Line 22.
25. Enter the dates, the amounts, and the sources of proceeds codes. Where applicable prorate according to Lines 26 and 27.  Any registered prior or preferred claims should be deducted before entering the amount of proceeds.
26. Indicate how the proceeds in Line 25 and costs in Line 28 and 29 are allocated.

    If costs are incurred and/or proceeds received, related to the CSBF loan, and other loans from the same lender, the costs and/or proceeds must be prorated between the respective loans in a manner that is fair and equitable to all parties; circumstances may justify a combination of them:

    1. where realization proceeds can be clearly identified with specific loans, prorate costs incurred on behalf of the combined loans on the basis of the amount realized for each;
    2. where neither realization proceeds nor costs can be clearly identified with individual loans, prorate proceeds and costs according to the unpaid principal amount of each outstanding loan at the date specified in the Notice of Default;
    3. where the above do not apply, prorate proceeds and/or costs according to the outstanding principal amount of each loan claimed in the statements of claim filed in the legal proceedings;
    4. where collection relates to personal guarantees or suretyships or personal obligations of sole proprietors or partners held for a CSBF loan and for a conventional loan, prorate costs and realization proceeds of this collection according to the lesser amount of the guarantee or the personal obligation (limited to 25% of the CSBF loan amount disbursed) or the principal outstanding on the loan on default.
27. Enter the percentage calculated by dividing the principal outstanding amount of the loan (line 23) by the principal outstanding amount of all loans (line 24) or any other appropriate percentages.
28. Enter the legal costs incurred by the lender in collecting or attempting to collect on the CSBF loan. Deduct any refundable amounts or credits. Attach a summary if necessary.
29. Enter the other costs incurred by the lender in collecting or attempting to collect on the CSBF loan. Deduct any refundable amounts or credits. Attach a summary if necessary.
30. Substract the total realization proceeds from the outstanding amount of loan and add the total legal and other costs.
31. Enter the amount of the holdback if this is an Interim Claim. Note that the holdback is the full amount of the guarantee(s) or suretyship(s) or the amount of the judgement or the compromise settlement. Include interest or any other costs that are set in the judgement or compromise settlement.
32. If an Interim Claim is submitted where only the realization of assets is completed, enter the date when the lender expects to be able to submit the Final Claim. (when the realization of guarantee(s) or suretyship(s) is expected to be completed) To maintain the CSBF Program’s insurance the lender must inform the CSBF Program before the date specified if there is a change to this date.
33. Based on the above figures provide the amount of the loss, excluding interest. Interest will be calculated by the Program based on the Act and Regulations.