Assessment Certificate Name of trustee or administrator of consumer proposal Name of debtor Date of assessment Name of registered individual who assisted in the performance of the assessment, if applicable. Individual Given Names Individual Family or Company Name Signed by trustee Check if the assessment was performed in a designated area or pursuant to the extraordinary circumstances provision Option chosen by debtor: (a)Consumer proposal, (b)Division 1 proposal or (c)Assignment in bankruptcy Identify if the Debtor has or has not received advice in the last 6 months Amount paid for other advice received, if applicable Debtor Declaration Provide any additional information related to the form.