You Owe Money—

Affidavit Form for Debtors

In the matter of (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 $ (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 (insert address at the time you filed for bankruptcy).

Sworn before me in the city of in the province of this day of , 20.

Commissioner for Oaths

Debtor

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