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Form 79—Statement of Affairs (Non-Business Bankruptcy/Proposal)

For persons to which the 2009 amendments apply

PDF and Word versions

Form 79 (PDF)

122 KB, 4 pages

Form 79 (Word)

152 KB, 4 pages

(Subsections 49(2) and 158(d) of the Act / Subsections 50(2) and 62(1) and Paragraph 66.13(2)(d) of the Act)


(Title Form 1)

□ Original           □ Amended

Assets

Type of assets

Description (provide details)

Estimated dollar value

Exempt property

Secured amount/ liens

Estimated net realizable dollar valueFootnote 1

Yes

No

1. Cash on hand

 

 

 

 

 

 

2. Furniture

 

 

 

 

 

 

3. Personal effects

 

 

 

 

 

 

4. Cash-surrender value of life insurance policies, RRSPs, etc.

 

 

 

 

 

 

5. Securities

 

 

 

 

 

 

6. Real property or immovables

House

 

 

 

 

 

 

 

Cottage

 

 

 

 

 

 

 

Land

 

 

 

 

 

 

7. Motor vehicle

Automobile

 

 

 

 

 

 

 

Motorcycle

 

 

 

 

 

 

 

Snowmobile

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

8. Recreational equipment

 

 

 

 

 

 

9. Estimated tax refund

 

 

 

 

 

 

10. Other assets

 

 

 

 

 

 

TOTAL

 

 

 

 

 

 

 

____________________

Date

_____________________________

Bankrupt/Debtor

 

Liabilities

 

 

 

Liabilities type code (LTC)

1 Real property or immovable mortgage or hypothec

2 Bank loans (except real property mortgage)

3 Finance company loans

4 Credit cards - bank/trust company issuers

5 Credit cards - other issuers

6 Taxes - federal/provincial/municipal

7 Student loans

8 Loans from individuals

9 Other

Creditor

Address, including postal code

Account No.

Amount of debt

Enter LTC

Unsecured

Secured

Preferred

1

 

 

 

 

 

 

2

 

 

 

 

 

 

3

 

 

 

 

 

 

4

 

 

 

 

 

 

5

 

 

 

 

 

 

6

 

 

 

 

 

 

7

 

 

 

 

 

 

8

 

 

 

 

 

 

9

 

 

 

 

 

 

10

 

 

 

 

 

 

11

 

 

 

 

 

 

12

 

 

 

 

 

 

13

 

 

 

 

 

 

14

 

 

 

 

 

 

15

 

 

 

 

 

 

16

 

 

 

 

 

 

17

 

 

 

 

 

 

18

 

 

 

 

 

 

19

 

 

 

 

 

 

20

 

 

 

 

 

 

 

TOTAL

Unsecured

 

 

 

 

 

TOTAL

Secured

 

 

 

 

TOTAL

Preferred

 

 

 

 

 

 

____________________

Date

_____________________________

Bankrupt/Debtor

 

A. Information relating to the affairs of the bankrupt/debtor

1. Family name:

Given names:

 

Date of birth:
______ / ____ / ___

YYYY/ MM / DD

2. Also known as:

3. Complete address, including postal code:

4. Marital status: (specify month and year of event if it occurred in the last five years)

_____  ______

Married

_____  ______

Single

_____  ______

Widowed

_____  ______

Separated

_____  ______

Divorced

_____  ______

Common-law partner

5. Full name of spouse or common-law partner:

6. Name of present employer:

Occupation (bankrupt/debtor):

7A. Number of persons in household family unit, including bankrupt/debtor:

7B. Number of persons 17 years of age or younger:

8. Have you operated a business within the last five years?

Yes

No

(If yes) Name, type and period of operation:

B. Within 12 months prior to the date of the initial bankruptcy event, have you, either in Canada or elsewhere:

9A. Sold or disposed of any of your property?

Yes

No

9B. Made payments in excess of the regular payments to creditors?

Yes

No

9C. Had any property seized by a creditor?

Yes

No

C. Within five years prior to the date of the initial bankruptcy event, have you, either in Canada or elsewhere:

10A. Sold or disposed of any property?

Yes

No

10B. Made any gifts to relatives or others in excess of $500?

Yes

No

                   

 

____________________

Date

_____________________________

Bankrupt/Debtor

 

D. Budget information: Attach Form 65 to this form

11A. Have you ever made a proposal under the Bankruptcy and Insolvency Act?   Yes ___   No ___

11B. Have you been bankrupt before in Canada?   Yes ____     No ____

(If yes, provide the following details for all insolvency proceedings: (a) filing date and location of the proceedings; (b) name of trustee or administrator; (c) if applicable, was the proposal successful; (d) date on which Certificate of Full Performance or Discharge was obtained.)

12. Do you expect to receive any sums of money that are not related to your normal income, or any other property within the next 12 months?   Yes ____   No ____

13. If you answered Yes to any of questions 8, 9 or 11, provide details:

14. Give reasons for your financial difficulties:

 

I, ____________________, of the _____ of ____________________ in the Province of __________________, do swear (or solemnly declare) that this statement is, to the best of my knowledge, a full, true and complete statement of my affairs on the _____ day of ______________ ______ and fully discloses all property and transactions of every description that is or was in my possession or that may devolve on me in accordance with the Bankruptcy and Insolvency Act.

 

SWORN (or SOLEMNLY DECLARED)

before me at ______________________________ (city, town or village),

in the Province of __________________________,

on this _____ day of __________________ ______.

 

Or

SWORN (or SOLEMNLY DECLARED) remotely by ____________________ (debtor’s name)

stated as being located in at___________ the (city, town, or village),

in the Province of _________

before me at ________________ the (city, town, or village),

in the Province  of _____________,

 on this _____ day of _______________ ______in accordance with provincial Regulation on Administering Oath or Declaration Remotely.


space to insert date
Commissioner of Oaths for the Province of

space to insert Bankrupt/Debtor
Signature of bankrupt/debtor


Footnote 1

For a summary administration, indicate value net of the direct realization costs referred to in Rule 128(1) of the Bankruptcy and Insolvency Act.

Return to footnote 1 referrer

Note:

If a copy of this form is sent electronically by means such as email, the name and contact information of the sender, prescribed in Form 1.1, must be added at the end of the document.

Important Notices

This form may not be completed online. It is provided here for reference purposes only.

The HTML version of this Form is not the official version. In the event of an inconsistency between the HTML and PDF versions of this Form, the PDF version prevails. Users are required to exercise due diligence with respect to the HTML version.

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