Office of the Superintendent of Bankruptcy Canada
osb.ic.gc.ca
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Estate Information Summary
Printable Version: Estate Information Summary (PDF Format, 191 KB, 2 pages)
Original Amended
I – Complete the following in all cases
Proceeding
Assignment Referral Bankruptcy order Proposal
Individual
Corporation
Income Trust
Estate Name
Occupation
Language
English French Other,
specify
English French Other,
specifyInd. date of birth
D
M
Y
Previous or current BIA proceeding?
Yes No
Yes No
If yes, enter estate number(s)
Indicate if previous bankruptcy
Yes No
Yes NoIf yes, how many?
Address (Street No. and Apt. No.)
Indicate if receivership
Yes No
Yes No
D
M
Y
City
Province
Postal code
Home telephone No.
(
)
-
Work telephone No.
(
)
-
Consumer debts only?
Yes No
Yes No
%
of the total debt is business
The debtor resides or has carried on business at the above address since:
D
M
Y
Highest level of education completed by joint bankrupt/debtor: (for statistical purposes only)
0-8 years
some high school
high school graduate
some post-
secondary
secondary
post-secondary certificate or diploma
university degree
refuses to answer
or does not know
Indicate if receivership
Yes
No
D
M
y
Joint Estate Name
Occupation
Language
English
French
Other specify
English
French
Other specify
Ind. date of birth
D
M
Y
Previous or current BIA proceeding?
Yes No
Yes No
If yes, enter estate number(s)
Indicate if previous bankruptcy
Yes No
Yes No
If yes, how many?
Highest level of education completed by joint bankrupt/debtor: (for statistical purposes only)
0-8 years
some high school
high school graduate
some post-
secondary
secondary
post-secondary certificate or diploma
university degree
refuses to answer
or does not know
Indicate if receivership
Yes
No
D
M
y
II – Complete the following if the debtor has guaranteed the debts of another person
N/A
The debtor is the guarantor of
Business debts
Consumer debts
Other specify
Business debts
Consumer debts
Other specify
Is the person bankrupt?
Name of persons whose debts are guaranteed
Amount guaranteed
Name of business if business debts
Yes
No
III – Complete the following if the debtor was previously or is presently in business
N/A
Trade name(s) if different from the estate name
Place of business
Nature of business
Corporation, partnership or sole proprietorship (specify)
Names of the partners if a partnership:
During the past 12 months, what was the maximum number of employees that you employed?
How long have you been in operation under this current legal name?
IV – Complete the following if the debtor is a corporation, including an income trust
Are the corporation's shares or units publicly traded?
Yes No
Yes No
Federal Charter?
Yes
Charter Number
No
Yes
Charter Number
No
Names of the Corporation's officers:
Name of person to be examined
Title
Telephone No.
(
)
-
Address (Street No. and Apt. No.)
City
Province
Postal code
Language
English
French
Other
specify
English
French
Other
specify
During the past 12 months, what was the maximum number of employees that you employed?
How long have you been in operation under this current legal name?
V – To be completed when filing a consumer proposal or amended consumer proposal
Terms of the Consumer Proposal: (choose one only of A, B, C or D)
A)
(number) payments of
$
for a total of
$
B)
A lump sum payment of
$
C)
A lump sum $ payment of
$
+
(number) payments of
$
for a combined total of
$
D) Other: please describe terms below
Anticipated Completion Date of Consumer Proposal:
D
M
Y
Amount outstanding on mortgage or hypothec on principal residence
$
VI – To be completed and signed by the trustee in all cases
Creditor's Meeting Suggested Time and Place
D
M
Y
Time
Location
Examination requested
Yes No Comments
Yes No Comments
Trustee Appointment
Name & Licence number of the Trustee or, if a Corporate Trustee, the name &
licence number of the person responsible for the administration of the estate.
Name & Licence number of the Trustee or, if a Corporate Trustee, the name &
licence number of the person responsible for the administration of the estate.
Licence number
A possible conflict of interest situation exists Yes No
If yes, explain:
Yes NoIf yes, explain:
Indemnification: N/A Deposit Guarantee Name of depositor or guarantor
N/A Deposit Guarantee Name of depositor or guarantor
Post bankruptcy tax refund assigned to trustee
Yes No
Yes No
Amount or extent of indemnity
Trustee absent when file submitted Amended summary to follow
Signature of Trustee
VII – Official receiver use only
Note: quote this number in all future correspondence
No.
-
-
Administration
Summary
Ordinary
Summary
Ordinary
Date of filing
D
M
Y
Type
Industry
District
Division
Court No.
Licence No. of appointed Trustee
As above
Other
As above
Other
Resp. O.R.
Assets
Liabilities
Security
Creditor's Meeting
As above
Or
Date
D
M
Y
Time
Location
Chairperson
O.R.
Trustee
O.R.
Trustee
Debtor Examination
Yes
No
Date
D
M
Y
Time
Location
Official Receiver Comments
Note to file
A
B
C
A
B
C
Official Receiver's Initials
Data Processing Initials
Document Production Initials
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