Form 79—Statement of Affairs (Bankruptcy/Proposal of an Individual) (New, coming into force in 2024)

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A. Information relating to the affairs of the Bankrupt/Debtor

1.1. Surname: _________________       

1.3. All other surnames (including surname at birth and any surname by which you have been known, if  different from above): ____________       

Given names: ___________

All former given names  (including given names at birth and any given names by which you have been known, if different from above): _________

1.2. Date of birth: ________

2. Address: _____________________________________________________________

3. Marital or civil status (Single; Common-law partner; Married or civil union; Separated; Divorced; Widowed) (Specify month and year of each event if they occurred in the last five (5) years): _________

4. Surname of spouse or common-law                Given names of spouse or common-law

partner: _________________                             partner: _________________

5.1. Employment status (Choose one) (Employed – full-time; Employed – part-time; Employed – Seasonal; Self-employed; Retired; Student; Deceased; Not employed): ______________

5.2. Occupation: _________________

5.3. Name of present or most recent employer: _________________

5.4. Period of employment: ________ to ________

6.1. Total number of persons in household family unit, including bankrupt/debtor (1; 2; 3; 4; 5; 6; 7+ (Please specify) ___): _____

6.2. Number of persons 17 years of age or younger (1; 2; 3; 4; 5; 6; 7+ (Please specify) ___): _____

7.1. In the last six (6) months, have you received professional advice regarding your financial situation other than from the Licensed Insolvency Trustee?                                    □ Yes               □ No

7.2. Name any and all providers of professional financial advice: Surname: _____  Given names: ____

7.3. Name the firm/organization of the individual provider of professional financial advice: ___________

7.4. Address of the firm/organization noted at 7.3: ______________________________

7.5. Total amount paid to date: $_________        7.6. Total remaining amount to be paid: $_________

8. List any business(es) you operated within the last five (5) years                        □ Not applicable

Trade name of business

Address

Nature of business/ Industry

Type of business (Corporation; Partnership; Sole proprietorship)

Percentage of bankrupt’s/ debtor’s interest in business

Period of operation (Date to Date)

Maximum number of employees in the past twelve (12) months

9. Have you previously been bankrupt or made a proposal under the Bankruptcy and Insolvency Act in Canada? If so, provide information on the proceedings.                         □ Yes               □ No

Estate number

Type of proceeding (Bankruptcy; Proposal)

Filing date

Location of the proceeding

Name of trustee or administrator

Date discharge or certificate of full performance was obtained

B. Budget Information: Attach Form 65 to this form

10. Within twelve (12) months prior to the date of the initial bankruptcy event, have you, either in Canada or elsewhere:

10.1. Made payments in excess of the regular payments to creditors?      □ Yes               □ No

10.2. Had any asset seized by a creditor?                                                         □ Yes               □ No

If yes, provide details: _______________________________________________________________

11. Within five (5) years prior to the date of the initial bankruptcy event, have you, either in Canada or elsewhere:

11.1. Sold, disposed of or transferred partially or in full any asset?            □ Yes               □ No

11.2. Made any gifts to relatives or others in excess of $1000?                    □ Yes               □ No

If yes, provide details: _______________________________________________________________

12. Do you expect to receive any sums of money that are not related to your normal income, or any other property within the next twelve (12) months?                                                                  □ Yes               □ No

If yes, provide details: _______________________________________________________________

13. Give reasons for your financial difficulties (Select all that apply and provide details): □ Loss of Income; □ Medical Reasons; □ Business Failure; □ Gambling; □ Addictions other than gambling; □ Relationship Breakdown; □ Tax Liabilities; □ Financial Support of Others; □ Student Debt; □ Legal Matters (Provide details); □ Moving/Relocation Expenses; □ Failed Proposal; □ Financial Mismanagement; □ Other (Please specify).

Provide relevant details:

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