You Owe Money—

Affidavit Form for Debtors

PDF and Word versions

Affidavit (PDF)

42 KB, 1 page

Affidavit (Word)

71 KB, 1 page

In the matter of space to insert estate number(s) or estate(s) name(s) (insert estate number(s) or estate name(s)) for unclaimed funds held by the Receiver General, I swear or say under penalty of perjury:

  1. That I am the debtor to whom the funds held are payable;
  2. That I have knowledge of the circumstances connected with this claim;
  3. That I have reason to believe that the Receiver General for Canada holds unclaimed funds to which I am entitled in the amount of $space to insert amount (insert amount);
  4. That I have not been reimbursed by a third party and the amounts are still owed to me;
  5. That I am entitled to request payment of the unclaimed funds pursuant to subsection 154(1) of the Bankruptcy and Insolvency Act;
  6. That I claim the unclaimed funds pursuant to subsection 154(2) of the Bankruptcy and Insolvency Act;
  7. That I agree and undertake to indemnify Her Majesty and her officers, officials, employees and agents if it is determined that I was not entitled to the funds; and
  8. That I live or that I have lived at space to insert address (insert address at the time you filed for bankruptcy).

Sworn before me in the city of space to insert city in the province of space to insert province this space to insert day day of space to insert month, 20space to insert year.

space to insert signature of Commissioner for Oaths
Commissioner for Oaths
space to insert signature of debtor
space to print name or stamp
Print name or stamp
space to print name
Print name