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

Statement of Affairs (Non-Business Bankruptcy/Proposal)

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

Electronic version: Form 79 (Microsoft Word, 152 KB, 4 pages)

Printable Version: Form 79 (PDF Format, 123 KB, 4 pages)

(Title of Asset)

Original Amended

Date

Bankrupt/Debtor

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

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

Date

Bankrupt/Debtor

Information relating to the affairs of the bankrupt/debtor

A. Personal Data

1. Family name:

Given names:

Gender
F M

Date of birth

 

 

 

MM / DD / YYYY

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

Widowed

Divorced

Single

Separated

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 the 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 the 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

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 you answered 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, whether the proposal was 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 9, 10 or 12, provide details:

I,

name

of

city, town or village

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

date

and fully discloses all property and transactions of every

before me at

city, town or village

in the Province of

on

date

Commissioner of Oaths

Bankrupt/Debtor

for the Province of

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