For persons to which the 2009 amendments do not apply
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(Subsections 68(6), 68(7) and 170.1(5))
(Title Form 1)
I, 
, trustee of the estate of , bankrupt, who made an assignment (or against whom a bankruptcy order was made) on the day of , hereby apply to the official receiver to refer this matter to the mediator, who shall set the time and place for the mediation.
(Check appropriate description)
Subsection 68(6) - There is disagreement as to the amount of surplus income to be paid by the bankrupt.
Subsection 68(7) - There is a written request from , a creditor, (creditor's address), to proceed with the mediation process.
Subsection 170.1(4) - The bankrupt does not agree with the discharge recommendation of the trustee.
Subsection 170.1(5) - The trustee is opposed to the discharge of the bankrupt on a ground referred to in paragraph 173(1)(m) or (n) of the Act.
Subsection 170.1(5) - , a creditor, (creditor's address), is opposed to the discharge of the bankrupt on a ground referred to in paragraph 173(1)(m) or (n) of the Act.
An income and expense statement of the bankrupt is attached to this request (Form 65).
(Indicate name, address, phone numbers of all parties)
Dated at , this day of .
Trustee