Statement of Affairs (Non-business bankruptcy) (Paragraph 158(d) of the Act) An asset of the bankrupt Type of this asset. Pick from list. Description and details of this asset Estimated dollar value of this asset. Must be entered for every Asset description and cannot be $0.00. True if asset is exempt Secured Amount / Liens Estimated net realizable dollar value Total dollar value of Asset Value Total dollar value of Secured Amount / Liens Total dollar value of Estimated Realizable Value A liability of the bankrupt At least one of Unsecured, Secured, or Preferred must be present. Name of creditor for this liability Address of creditor including postal code Account number Value of debt and if it's Unsecured, Secured or Preferred Dollar value of debt Debt type - Unsecured, Secured or Preferred Liabilities type code. Pick from list. Total of unsecured liabilities Total of secured liabilities Total of preferred liabilities Total of all liabilites Pledged Asset A. Personal Data 1. Gender of Bankrupt 1. Birth date of bankrupt person 2. Alias name (Also known as) Person's Given Names Person's Family Name 3. Address of bankrupt 4. Current marital status 4. Year and month of event if within the last five years 5. Full name of spouse or common-law partner 6. Name of present employer 7A. Number of persons in household family unit including the bankrupt 7B. Number of household members 17 years of age or less 8. Details of business operated by bankrupt within the last five years. Name of business, if applicable BusinessType Period Of Operation identified using dates. Period Of Operation identified using free-form text. 9. Within the last 12 months prior to the initial bankruptcy event 9A. True if debtor sold or disposed of any property 9B. True if debtor made payments in excess of the regular payments to creditors 9C. True if debtor had any property seized by a creditor 10. Within the last 5 years prior to initial bankruptcy event, while knew self to be insolvent 10A. True if debtor sold or disposed of any property 10B. True if debtor made any gifts to relatives or others > $500 11A. True if the debtor ever made a proposal under the Bankruptcy and Insolvency Act 11B. True if the debtor had ever been a bankrupt before, either in Canada or elsewhere Details of a prior insolvency proceeding, if applicable. ((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. True if debtor expects to receive money not related to normal income, or any other property within the next 12 months 13. Details explaining 9, 10 and 12, if true. 14. Reasons for financial difficulty. Date of this statement of affairs. Bankrupt Declaration Provide any additional information related to the form.