For persons to which the 2009 amendments apply
(Subsections 49(2) and 158(d) of the Act / Subsections 50(2) and 62(1) and Paragraph 66.13(2)(d) of the Act)
(Title Form 1)
Type of assets
Description (provide details)
Estimated dollar value
Secured amount/ liens
Estimated net realizable dollar valueFootnote 1
1. Cash on hand
3. Personal effects
4. Cash-surrender value of life insurance policies, RRSPs, etc.
6. Real property or immovables
7. Motor vehicle
8. Recreational equipment
9. Estimated tax refund
10. Other assets
Liabilities type code (LTC)
1 Real property or immovable mortgage or hypothec
2 Bank loans (except real property mortgage)
3 Finance company loans
4 Credit cards - bank/trust company issuers
5 Credit cards - other issuers
6 Taxes - federal/provincial/municipal
7 Student loans
8 Loans from individuals
Address, including postal code
Amount of debt
A. Information relating to the affairs of the bankrupt/debtor
1. Family name:
Date of birth:
YYYY/ MM / DD
2. Also known as:
3. Complete address, including postal code:
4. Marital status: (specify month and year of event if it occurred in 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 bankrupt/debtor:
7B. Number of persons 17 years of age or younger:
8. Have you operated a business within the last five years?
(If yes) Name, type and period of operation:
B. Within 12 months prior to the date of the initial bankruptcy event, have you, either in Canada or elsewhere:
9A. Sold or disposed of any of your property?
9B. Made payments in excess of the regular payments to creditors?
9C. Had any property seized by a creditor?
C. Within five years prior to the date of the initial bankruptcy event, have you, either in Canada or elsewhere:
10A. Sold or disposed of any property?
10B. Made any gifts to relatives or others in excess of $500?
D. Budget information: Attach Form 65 to this form
11A. Have you ever made a proposal under the Bankruptcy and Insolvency Act? Yes ___ No ___
11B. Have you been bankrupt before in Canada? Yes ____ No ____
(If yes, provide the following details for all insolvency proceedings: (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. Do you expect to receive any sums of money that are not related to your normal income, or any other property within the next 12 months? Yes ____ No ____
13. If you answered Yes to any of questions 8, 9 or 11, provide details:
14. Give reasons for your financial difficulties:
I, ____________________, of the _____ of ____________________ in the Province of __________________, do swear (or solemnly declare) that this statement is, to the best of my knowledge, a full, true and complete statement of my affairs on the _____ day of ______________ ______ and fully discloses all property and transactions of every description that is or was in my possession or that may devolve on me in accordance with the Bankruptcy and Insolvency Act.
SWORN (or SOLEMNLY DECLARED)
before me at ______________________________ (city, town or village),
in the Province of __________________________,
on this _____ day of __________________ ______.
SWORN (or SOLEMNLY DECLARED) remotely by ____________________ (debtor’s name)
stated as being located in at___________ the (city, town, or village),
in the Province of _________
before me at ________________ the (city, town, or village),
in the Province of _____________,
on this _____ day of _______________ ______in accordance with provincial Regulation on Administering Oath or Declaration Remotely.
Commissioner of Oaths for the Province of
Signature of bankrupt/debtor
- Footnote 1
For a summary administration, indicate value net of the direct realization costs referred to in Rule 128(1) of the Bankruptcy and Insolvency Act.
If a copy of this form is sent electronically by means such as email, the name and contact information of the sender, prescribed in Form 1.1, must be added at the end of the document.
This form may not be completed online. It is provided here for reference purposes only.
The HTML version of this Form is not the official version. In the event of an inconsistency between the HTML and PDF versions of this Form, the PDF version prevails. Users are required to exercise due diligence with respect to the HTML version.