Individual Affidavit Form

PDF version

Affidavit Form

42 KB, 1 page

Word version

75 KB, 1 page

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 Dividends Database) for unclaimed dividends held by the Receiver General, I swear or say under penalty of perjury:

  1. That I am entitled to the unclaimed dividends specified in the claim attached hereto, as I am the individual creditor to whom the funds held are payable, or his or her legal representative;
  2. That I have knowledge of all the circumstances connected with this claim;
  3. That I have reason to believe that the Receiver General for Canada holds unclaimed dividends to which I am entitled in the amount of $ space to insert estate unclaimed dividend or unclaimed dividends;
  4. That I have not been reimbursed by a third party and the amounts are still owed to me;
  5. That I am entitled to request payment of the unclaimed dividend held in trust pursuant to subsection 154(1) of the Bankruptcy and Insolvency Act;
  6. That I claim the unclaimed dividend pursuant to subsection 154(2) of the Bankruptcy and Insolvency Act;
  7. That I agree and undertake to indemnify Her Majesty and her officers, officials, employees and agents if it is determined that I was not entitled to the funds;
  8. That I live or that I have lived at space to insert address from the Unclaimed Dividends Database (insert address from Unclaimed Dividends Database); and
  9. 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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