Proof of Claim (Section 50.1, subsections 65.2(4), 81.2(1), 81.3(8), 81.4(8), 102(2), 124(2), 128(1), and paragraphs 51(1)(e) and 66.14(b) of the Act) Address where all notices or correspondence regarding this claim must be forwarded Name of Debtor in the matter of Bankruptcy, Proposal or Receivership Name of Creditor Creditor (or Representative acting for the Creditor) stating the Claim Enter information related to person representing the creditor. Name of Creditor being represented Position or Title of representative. Date of bankruptcy, receivership, notice of intention or the proposal if there was no notice of intention. Amount the Debtor is indebted to the Creditor as of the Bankruptcy Date Unsecured Unsecured Claim Amount Amount of money the creditor does not claim a right to a priority. Amount of money the creditor does claim a right to a priority under section 136 of the Act. Lease Amount of claim of landlord for disclaimer of a lease Full particulars of the claim, including the calculations upon which the claim is based. Secured Secured Claim Amount Dollar amount of the assets being held of the debtor. Full particulars of the security, including the date on which the security was given. The assessed value of the security Claim by farmer, fisherman or aquaculturist Amount of claim by a farmer, fisherman or aquaculturist Amount of claim for the unpaid amount under subsection 81.2(1) of the Act Claim by wage earner Amount of claim by a wage earner Amount of claim under subsection 81.3(8) of the Act Amount of claim under subsection 81.4(8) of the Act Director Amount of claim against the director if a proposal provides for the compromise of claims against directors. Full particulars of the claim, including the calculations upon which the claim is based. Securities Firm Amount of claim of a customer of a bankrupt securities firm Full particulars of the claim, including the calculations upon which the claim is based. The payments received from, and the credits allowed to, the debtor. Payment Details Credit Details That, to the best of my knowledge, I am or am not related to the debtor within the meaning of section 4 of the Act. Have or have not dealt with the debtor in a non arm's length manner. Requests applicable only in the case of the bankruptcy of an individual. Request to be advised of any material change in the financial situation of the bankrupt. Request to be advised of any amendment made regarding the amount amount that the bankrupt is required to pay. Request a copy of the report filed by the trustee regarding the bankrupt's application for discharge. Signed At Location and Date Signed for creditor by Signing Witness Witness' Phone Number Witness' Fax Number Witness' Email Address Provide any additional information related to the form.