For persons to which the 2009 amendments apply
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(Subsection 49(2) and Paragraph 158(d) of the Act / Subsections 50(2) and 62(1) of the Act)
(Title Form 1)
Original Amended
To the bankrupt/debtor:
You are required to carefully and accurately complete this form and the applicable attachments showing the state of your affairs on the date of your bankruptcy / date of filing your proposal (or, if applicable, notice of intention) on the _____ day of _______________ ______. When completed, this form and the applicable attachments will constitute your Statement of Affairs and must be verified by oath or solemn declaration.
| empty cell | Amounts |
|---|---|
| 1. Unsecured creditors as per list "A" | $ |
| 2. Secured creditors as per list "B" | $ |
| 3. Preferred creditors as per list "C" | $ |
| 4. Contingent, trust claims or other liabilities as per list "D" estimated to be reclaimable for | $ |
| Total liabilities | $ |
| Surplus | $ |
| empty cell | Amounts |
|---|---|
| 1. Inventory | $ |
| 2. Trade fixtures, etc. | $ |
| 3. Accounts receivable and other receivables as per list "E" | |
| Good $ | |
| Doubtful $ | |
| Bad $ | |
| Estimated to produce $ | $ |
| 4. Bills of exchange, promissory note, etc. as per list "F" | $ |
| 5. Deposits in financial institutions | $ |
| 6. Cash | $ |
| 7. Livestock | $ |
| 8. Machinery, equipment and plant | $ |
| 9. Real property or immovables as per list "G" | $ |
| 10. Furniture | $ |
| 11. RRSPs, RRIFs, life insurance, etc. | $ |
| 12. Securities (shares, bonds, debentures, etc.) | $ |
| 13. Interests under wills | $ |
| 14. Vehicles | $ |
| 15. Other property as per list "H" | |
| $ | |
| $ | $ |
| If bankrupt/debtor is a corporation, add: | |
| Amount of subscribed capital | $ |
| Amount paid on capital | $ |
| Balance subscribed and unpaid | $ |
| Estimated to produce | $ |
| Total assets | $ |
| Deficiency | $ |
I, ______________________, of the _____________ of __________________________ in the Province of __________________, do swear (or solemnly declare) that this statement and the attached lists are, to the best of my knowledge, a full, true and complete statement of my affairs on the _____ day of ______________ ______ and fully disclose all property of every description that is in my possession or that may devolve on me in accordance with the Act.
SWORN (or SOLEMNLY DECLARED) before me at ____________________ (city, town or village), in the Province of _________________, on this _____ day of _______________ ______.
Or
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
List "A"
Unsecured Creditors
Names to be arranged in alphabetical order and numbered consecutively.
No. | Name of creditor | Address | Amount of claim |
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__________________________
Bankrupt/Debtor
__________________
Date
List "B"
Secured Creditors
No. | Name of Creditor | Address | Amount of claim | Particulars of security | When given | Estimated value of security | Estimated surplus from security | Balance of claim unsecured |
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__________________________
Bankrupt/Debtor
__________________
Date
List "C"
Preferred Creditors for Wages, Rent, etc.
No. | Name of creditor | Address and occupation | Nature of claim | Period during which claim accrued | Amount of claim | Amount payable in full | Difference ranking for dividend |
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__________________________
Bankrupt/Debtor
__________________
Date
List "D"
Contingent or Other Liabilities
Give particulars of claims not set out in lists "B" or "C."
No. | Name of creditor or claimant | Address and occupation | Amount of liability or claim | Amount expected to rank for dividend | Date when liability incurred | Nature of liability |
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__________________________
Bankrupt/Debtor
__________________
Date
List "E"
Debts Due to the Bankrupt/Debtor
No. | Name of debtor | Address and occupation | Nature of debt | Amount of debt (good, doubtful, bad)
| Folio of ledgers or other book where particulars to be found | When contracted
| Estimated to produce
| Particulars of any securities held for debt
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__________________________
Bankrupt/Debtor
__________________
Date
List "F"
Bills of Exchange, Promissory Notes, Lien Notes, Chattel
Mortgages, etc. Available as Assets
No. | Name of all promissory, acceptors, endorsers, mortgagors and guarantors | Address | Occupation | Amount of bill or note, etc. | Date when due | Estimated to produce
| Particulars of any property held as security for payment of bill or note, etc.
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__________________________
Bankrupt/Debtor
__________________
Date
List "G"
Real Property or Immovables Owned by Bankrupt/Debtor
Description of property | Nature of bankrupt’s/ debtor’s interest | In whose name does title stand
| Total value | Particulars of mortgages, hypothecs or other encumbrances (name, address, amount) | Equity or surplus
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__________________________
Bankrupt/Debtor
__________________
Date
List "H"
Property
Give full particulars of property of every description that is in the bankrupt's/debtor’s possession or that may devolve on the bankrupt/debtor in accordance with the Act and that is not included in any other list.
FULL STATEMENT OF PROPERTY
Nature of property | Location | Details of property | Original cost | Estimated to produce |
a) Stock-in-trade |
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b) Trade fixtures, etc. |
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c) Cash in financial institutions (name) (address) |
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d) Cash on hand |
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e) Livestock |
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f) Machinery, equipment and plant |
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g) Furniture |
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h) Life insurance policies, RRSPs, etc. |
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i) Securities |
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j) Interests under wills, etc. |
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k) Vehicles |
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l) Taxes |
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m) Other property (state particulars) |
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__________________________
Bankrupt/Debtor
__________________
Date
Note: 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