Family Name:

Given Names:

Gender:

Date of Birth:

Complete Address:

Since when:

Has gone by any other names?

House Phone #:

Work Phone #:

S.I.N.:

E-mail Address:

Name of Employer:

Occupation:

Address:

Marital Status & Date (MM/YY):

Dependents 17 and Under:

Adults:

Spouse's Family Name:

Given Names:

Date of Birth:

S.I.N.:

Name and Address of Employer:

Occupation:

Have you operated a business within the last 5 years?

(If yes) Name, type and period of operations:

Within the last 12 months have you: (Provide Details)

(a) Disposed of or transferred any of your assets:

(b) Made payments in excess of regular payments to a creditor:

(c) Had any assets seized by creditors:

Within the last 5 years have you: (Provide Details)

(a) Sold, disposed of or transferred any real estate:

(b) Made any gifts to relatives or others in excess of $500:

Do you expect to receive any money other than regular income, or any property over the next 12 months?

Do you have a safe deposit box?

Have you ever been bankrupt

or have filed a consumer proposal?

Date of bankruptcy or proposal:

Date of absolute discharge or compliance:

Trustee or Administrator:

Budget
Monthly Income			Total
Net Employment Income
Net Pension/Annuities
Net Child Support
Net Spousal Support
Net E.I. Benefits
Net Social Assistance
Self Employment Income
Other Net Income
Total Monthly Income
Total Monthly Income of Family Unit

Monthly Non-discrentionary Expenses
Child Support Payments
Spousal Support Payments
Child Care
Medical Condition Expenses
Fines/Penalties Imposed by Court
Expenses as Condition of Employment
Debts Where Stay is Lifted
Other Expenses


Total Monthly Non-Discretionary Expenses
Total For Family Unit

Monthly Discretionary Expenses (family unit)
Housing Expenses		Living Expenses
Rent/Mortgage		Food/Grocery
Property Taxes/Condo Fees		Laundry/Dry Cleaning
Heating (Gas/Oil)		Grooming/Toiletries
Telephone		Clothing
Cable		Other
Electricity		Other
Water		Transportation Expenses
Furniture		Car/Lease Payments
Other		Repair/Maintenance/Gas
		Public Transit
Personal Expenses		Other
Smoking
Alcohol		Insurance Expenses
Dining/Lunches/Restaurants		Vehicle
Entertainment/Sports		House
Gifts/Charitable Donations		Furniture/Contents
Allowances		Life Insurance
Other		Other

Non-Recoverable Medical Exp.		Payments
Prescriptions		To the Estate
Dental		To Secured Creditors
Other		Other (than mortgage or vehicle)
Total Monthly Discretionary Exp. of the Family Unit

Assets
Type of Assets		Description (Provide details)	Estimated Dollar Value	Exempt Property	Secured Amount/Liens	Estimated net realizable dollar value*
1. Cash on hand
2. Furniture
3. Personal effects
4. Cash-surrender value of life insurance policies, RRSP's, etc.
5. Securities
6. Real Property
	House
	Cottage
	Land
7. Motor Vehicle
	Automobile
	Motorcycle
	Snowmobile
	Other
8. Recreational equipment
9. Estimated tax refund
10. Other assets
TOTAL

Liabilities
Creditor	Address including postal code	Account No.	Amount of debt
Creditor	Address including postal code	Account No.	Unsecured	Secured	Preferred













	Total

Tax Information

List all employers for past 2 years. In periods when drawing EI show each period separately.
Mr.

Year	Employer's Name	Address

Mrs.

Year	Employer's Name	Address

For which year was your last income tax return filed?
Amount Owing
Refund

Dependents (List all dependents who rely on you for financial support)

Name	Relationship	Birth Date

Details of motor vehicles owned in the past two years (if applicable)

Details on alimony or maintenance payments (note whether payments are taxable or tax deductible)

Details of any present garnishments or attachments

Describe briefly the circumstances that caused your financial problems

Have you any credit cards? Yes No
Have you received, or do you expect to receive an inheritance? Yes No
Have you obtained any credit in the last 3 months? Yes No
Has anyone guaranteed a debt for you? Yes No
Have you guaranteed a debt for anyone? Yes No

Budget

Assets

Liabilities

Tax Information