Intake Form

Home

Intake Form

Book an Appointment

Step 1 of 12

Assessment / Intake Form

Debtor

Personal Information

Full legal name (As on your Birth Certificate/Passport/Citizenship Card)(Required)

First Name Middle Name Last Name

Are you now or in the last five years been known by any other name? If so what names?

Birth date(Required)

DD slash MM slash YYYY

S.I.N(Required)

Employment Type(Required)

At Home

Employed

Employment Insurance

Retired

Self-employed

Unemployed

Welfare

Level of Education(Required)

0-8 Years

some High School

High School Graduate

Some Post-secondary

Post-secondary certificate/diploma

University Degree

Refuse to answer or no know

Current marital status(Required)

Married

Single

Widowed

Common Law

Separated

Divorced

Date of Marriage/Separation/Divorce if applicable

DD slash MM slash YYYY

Driver's License No

Contact Information

Address(Required)

Street Address City Province Postal Code

You have resided at this residence since(Required)

DD slash MM slash YYYY

Previous Addresses

List addresses resided at over the past 10 Years beginning with the most recent if not at present location for five years and dates lived there:

Email(Required)

Home Phone

Mobile

Home Fax

Work Phone

Alternate Contact Name(Required)

First Last

A person who does not live at the same address of the applicant

Alternate Contact Phone(Required)

Relationship to debtor(Required)

Income Sources

Current income situation(Required)

Employed

Unemployed

Self-Employed

Two jobs

Part-time

Pension

CPP

OAS

Other

Primary Occupation(Required)

Primary Employer's name

Primary Employer's Address

Street Address City Province Postal Code

Employed since

DD slash MM slash YYYY

Are you bonded in your present job?

Yes

Job #2

Job #2 Occupation

Job #2 - Employer's name

Job #2 - Employer's Address

Street Address City Province Postal Code

Job #2 - Employed since

DD slash MM slash YYYY

Job #2 - Are you bonded in your present job?

Yes

Employment History

List all employers (except present employer) since the year of the last tax return filed; also specify periods of Employment Insurance (EI) benefits.

If the assessment is joint, list spouse's employers/EI also, and mark with "S" in the far right column.

History

Employer's Name

Address

Started

Ended

Spouse

If you received Employment Insurance (E.I) benefits this year or last year, give the following information:

Date benefits started

DD slash MM slash YYYY

Date benefits ceased

DD slash MM slash YYYY

Which office granted E.I. benefit?

Debtor's Business Involvement

If you have been self-employed or operated a business in the past five years, please complete the following:

Have you ever operated a business?

Yes

Have you been self-employed (Past five years)?(Required)

Yes

Are any of the debts business debts?(Required)

Yes

What percentages of debt is from business?

Fill-in %

Business 1

Business 1 - Business Name and start date

Business 1 - Address

Street Address City Province Postal Code

Type of Business

Business still operating?

Yes

If no, when did it cease to operate

DD slash MM slash YYYY

Sole Proprietorship

Yes

Partnership

Yes

If yes, names of partners

Percentage for each partner:

Self %

2 %

3 %

Corporation

Yes

If yes, date of incorporation

DD slash MM slash YYYY

Business 1 - Business No.

i.e. 12345 6789

Business 1 - GST Registration No.

i.e. 12345 6789 RT0001

Business 1 - Payroll Acct. No.

i.e. 12345 6789 RP0001

Have you guaranteed any business loans?

Yes

If yes, give details

Business 1 - Last period/quarter for which you filed a GST return?

Business 1 - When is/was fiscal year end?

Business 2

Business 2 - Business Name and start date

Business 2 - Address

Street Address City Province Postal Code

Business 2 - Type of Business

Business 2 still operating?

Yes

If no, when did it Business 2 cease to operate

DD slash MM slash YYYY

Sole Proprietorship

Yes

Partnership

Yes

If yes, names of partners

Percentage for each partner:

Self %

Partner 2 %

Partner 3 %

Business 2 - Business No.

i.e. 12345 6789

Business 2 - GST Registration No.

i.e. 12345 6789 RT0001

Business 2 - Payroll Acct. No.

i.e. 12345 6789 RP0001

Have you guaranteed any business loans?

Yes

If yes, give details

Business 2 - Last period/quarter for which you filed a GST return?

Business 2 - When is/was fiscal year end?

Are you now an officer or director, or involved in any managerial capacity in any corporation? If so, give the name of the company, your title or position and date you started.

Are you now an officer or director, or involved in any managerial capacity in any corporation which became bankrupt or which made a proposal or arrangement with its creditors? If so, give the name of the company, your title or position and details of the bankruptcy or proposal.

Bankruptcy History

Have you ever been bankrupt before?(Required)

Yes

Trustee's name

Bankruptcy Date

DD slash MM slash YYYY

Place Bankruptcy was Filed

Discharge Date

DD slash MM slash YYYY

Reason for previous bankruptcy

Tax Returns

For which year was your last tax return filed?(Required)

Refund Received?(Required)

Yes

Refund to come?(Required)

Yes

Amount Owed(Required)

Taxes Paid(Required)

Address when you filed that return?(Required)

Street Address City Province Postal Code

Have you filed prior year's income tax returns?(Required)

Yes

Years not filled

Did you register for G.S.T. rebate?(Required)

Yes

Debtor's Spouse/Partner

Full legal name (As in your Birth Certificate/Passport/Citizenship Card)

First Middle Last

Are you now or in the last five years been known by any other name? If so what names?

Birth date

DD slash MM slash YYYY

Partner/Spouse's S.I.N

Only Legal Name, SIN and birthdate are required for spouse not seeking Bankruptcy and Insolvency Act protection

Spouse/Partner Employment Type

At Home

Employed

Employment Insurance

Retired

Self-employed

Unemployed

Welfare

Spouse/Partner - Date of Separation/Divorce if applicable

DD slash MM slash YYYY

Spouse/Partner - Contact Information

Spouse/Partner resides at the same address of primary applicant

Yes

Spouse/Partner - Address

Street Address City Province Postal Code

Spouse/Partner's Email

Spouse/Partner's Home Phone

Spouse/Partner's Mobile

Spouse/Partner's Fax

Spouse/Partner's Work Phone

Spouse/Partner - You have resided at this residence since

DD slash MM slash YYYY

Spouse/Partner's Previous Adresses

List addresses resided at over the past 10 Years beginning with the most recent if not at present location for five years and dates lived there:

Spouse/Partner - Alternate Contact

Name

Phone

Relationship to Debtor

Not living at the same residence

Level of Education

0-8 Years

some High School

High School Graduate

Some Post-secondary

Post-secondary certificate/diploma

University Degree

Refuse to answer or no know

Spouse/Partner's Information

Spouse/Partner's current income sources

Employed

Unemployed

Self-Employed

Two jobs

Part-time

Pension

WSIB

CPP

OAS

Spouse/Partner's Occupation

Income Source's name

Employer's Address

Street Address City Province Postal Code

Employed since

DD slash MM slash YYYY

Are you bonded in your present job?

Yes

Spouse/Partner's - Job #2

Occupation

Spouse/Partner - Employer's name

Spouse/Partner - Employer's Address

Street Address City Province Postal Code

Spouse/Partner - Employed since

DD slash MM slash YYYY

Spouse/Partner - Are you bonded in your present job?

Yes

Spouse/Partner - Employment History

History

Employer's Name

Address

Started

Ended

If you received Employment Insurance (E.I) benefits this year or last year, give the following information:

Date benefits started

DD slash MM slash YYYY

Date benefits ceased

DD slash MM slash YYYY

Which office granted E.I. benefit?

Spouse/Partner's Business Involvement

If you have been self-employed or operated a business in the past five years, please complete the following:

Spouse/Partner - Have you ever operated a business?

Yes

Spouse/Partner - Have you been self-employed in the past five years?

Yes

Are any of the debts business debts?

Yes

What percentages of the debts are from business?

Fill-in %

Spouse/Partner's Business 1 - Business Name and start date (Business 1)

Spouse/Partner's - Business 1 Address

Street Address City Province Postal Code

Spouse/Partner's Business 1 - Type of Business

Business still operating?

Yes

If no, when did it cease to operate

DD slash MM slash YYYY

Sole proprietorship?

Yes

Partnership?

Yes

If yes, names of partners

Percentage for each partner:

Self %

2 %

3 %

Spouse's Business 1 - Business No.

i.e. 12345 6789

Spouse's Business 1 - GST/HST Registration No.

i.e. 12345 6789 RT0001

Spouse's Business 1 - Payroll Acct. No.

i.e. 12345 6789 RP0001

Have you guaranteed any business loans?

Yes

If yes, give details

Spouse/Partner's Business 1 - Last period/quarter for which you filed a GST return?

Spouse/Partner's Business 1 - When is/was fiscal year end?

Spouse's Business 2 - Business Name and start date

Spouse/Partner's Business 2 Address

Street Address City Province Postal Code

Spouse/Partner's Business 2 - Type of Business

Business still operating?

Yes

If no, when did it cease to operate

DD slash MM slash YYYY

Sole proprietorship?

Yes

Partnership?

Yes

If yes, names of partners

Percentage for each partner:

Self %

Partner 2 %

Partner 3 %

Spouse's Business 2 - Business No.

i.e. 12345 6789

Spouse's Business 2 - GST/HST Registration No.

i.e. 12345 6789 RT0001

Spouse's Business 2 - Payroll Acct. No.

i.e. 12345 6789 RP0001

Have you guaranteed any business loans?

Yes

If yes, give details

Spouse/Partner's Business 2 - Last period/quarter for which you filed a GST return?

Spouse/Partner's Business 2 - When is/was fiscal year end?

Are you now an officer or director, or involved in any managerial capacity in any corporation? If so, give the name of the company, your title or position and date you started.

Are you now an officer or director, or involved in any managerial capacity in any corporation which became bankrupt or which made a proposal or arrangement with its creditors? If so, give the name of the company, your title/position and details of the bankruptcy or proposal.

Bankruptcy History

Have you ever been bankrupt before?

Yes

Trustee's name

Bankruptcy Date

DD slash MM slash YYYY

Place Bankruptcy was Filed

Discharge Date

DD slash MM slash YYYY

Reason for previous bankruptcy

Are any of the debts business debts?

Yes

What percentages of the debts are from business?

Fill-in %

Tax Returns

For which year was your last tax return filed?

Refund Received?

Yes

Refund to come?

Yes

Amount Owed

Taxes Paid

Address when you filled that return?

Street Address City Province Postal Code

Have you filed prior year's income tax returns?

Yes

Years not filled

Did you register for G.S.T. rebate?

Yes

Circumstances causing financial problems

How did you hear about Dana MacRae – LIT?(Required)

Newspaper ad

Community Agency

Social Services

Pamphlet

Yellow Pages

Walk In

Office Sign

Referral

Number of dependants(Required)

Total number of creditors(Required)

Total Debt owed $(Required)

Available for repayment $(Required)

Please describe briefly the circumstances that have caused your financial difficulties and what collection actions creditors are now taking if any.

Dependants

ALL DEPENDANTS THAT LIVE WITH YOU WHO RELY ON YOU FOR FINANCIAL SUPPORT

List of dependants

Full Name

Relationship

Date of Birth (dd/mm/yy)

Income (per month)

S.I.N

If over 18 years old, explain why they are still a dependent:

Alimony / Maintenance

If you paid alimony or maintenance during the last year, to whom were they paid?

Name

First Last

Address

Street Address City Province Postal Code

Amount Paid

Arrears Amount

Do you have a Separation Agreement

Yes

Do you have a Court Order

Yes

Do you have a Prenuptial Agreement?

Yes

If yes, please date

DD slash MM slash YYYY

Is the Prenuptial Agreement written?

Yes

If yes, will you provide a copy?

Yes

Self Employed Business Operating Budget Information

Gross Income(Required)

Gross Income

List sources of income

Total Monthly Net Income(Required)

FILLING INSTRUCTIONS

Please select the boxes with the appropriate expenses and then fill in the monthly amount you spend on each one of the selected categories.

Applicable Expenses

Rent

Property Taxes

Advertising

Meals and Entertainment

Bad Debts

Insurance

Interest

Business tax

Fees, licenses, dues, memberships

Office expenses

Supplies

Legal, accounting, other professional

Management and admin fees

Maintenance and repairs

Salaries and wages

Employee benefits

Travel (Transportation fees)

Travel (Accommodations)

Telephone and utilities

Fuel costs (except for motor vehicles)

Delivery, freight and express

Motor vehicle expenses

Additional Expenses

Rent

Property Taxes

Advertising

Meals and Entertainment

Bad Debts

Insurance

Interest

Business tax

Fees, licenses, dues, memberships

Office expenses

Supplies

Legal, accounting, other professional

Management and admin fees

Maintenance and repairs

Salaries and wages

Employee benefits

Travel (Transportation fees)

Travel (Accommodations)

Telephone and utilities

Fuel costs (except for motor vehicles)

Delivery, freight and express

Motor vehicle expenses

Other Expenses

Please list other expenses

Total Monthly Expenses(Required)

Calculated automatically

Total Monthly Net Income(Required)

Calculated automatically

Supplementary Information

Within the last 12 months, have you…

Disposed of or transferred any of your assets?

Yes

What

To Whom and what was done with the proceeds?

Amount Received

Paid any creditor in full or made a larger payment than usual to any of your creditors?

Yes

To Whom

Date of Payment

DD slash MM slash YYYY

Amount Paid

To Whom

Date of Payment

DD slash MM slash YYYY

Amount Paid

Had any assets seized by any creditor?

Yes

By Whom

When

DD slash MM slash YYYY

What

By Whom

When

DD slash MM slash YYYY

What

Given any security to any creditor?(Required)

Yes

1st Security Given - To Whom?

1st Security Given - When?

DD slash MM slash YYYY

1st Security Given - What?

1st Security Given - Why?

2nd Security Given - To Whom?

2nd Security Given - When?

DD slash MM slash YYYY

2nd Security Given - What?

2nd Security Given - Why?

Within the last 5 years, have you....

Sold, disposed of or transferred any real estate?

Yes

Address of Property

Street Address City Province Postal Code

When

DD slash MM slash YYYY

To Whom

For how much?

What did you do with the proceeds?

Made gifts to relatives or others in excess of $500.00?

Yes

What

To Whom

Value of Gift

Date

MM slash DD slash YYYY

Have you any debts arising from....

Fines or penalty Imposed by Court?

Yes

Fines or penalty imposed by Court, please explain

Recognizance or bail?

Yes

Recognizance or bail, please explain

Fraud?

Yes

Fraud, please explain

Misappropriation?

Yes

Misappropriation, please explain

Maintenance & support of separated family?

Yes

Maintenance & support of separated family, please explain

Alimony/Spousal support?

Yes

Alimony/Spousal support, please explain

Defalcation while Acting in a Fiduciary Capacity?

Yes

Defalcation while Acting in a Fiduciary Capacity, please explain

Embezzlement?

Yes

Embezzlement, please explain

Obtained property by false pretense or fraudulent misrepresentation?

Yes

Obtained property by false pretense or fraudulent misrepresentation, please explain

Have you applied for a Consolidation Order, Consolidation loan or received any previous credit counselling?

Yes

Do not understand

Have you applied for a Consolidation Order, Consolidation loan or received any previous credit counselling, give details

Have you made an assignment of your wages?

Yes

Have you made an assignment of your wages, give details

Have you made any arrangements to continue to pay any creditors?

Yes

Have you made any arrangements to continue to pay any creditors, give details

During the last three months have you: returned any goods, property or money to any of your creditors?

Yes

During the last three months have you: returned any goods, property or money to any of your creditors, give details

Residential Rental Information

If renting, please provide the following information since your last filed tax return:

History

Address of main Residence

Number of months

Monthly rent

Rent paid

Name and Address of Landlord

Assets

Cash in hand

Total amount of available cash in hand (money bill and coins)

Currency

Please list the amount of cash available and currency (if not in Canadian Dollar)

Financial Institutions

Funds in Banks

Name of Bank

Full Branch Address

Transit No & Account No (available on cheque)

Total amount of available funds in banks

Total of all accounts

Furniture and Appliances

Please add the estimated value you think your furniture and appliances could be sold for in an auction. This includes beds, lamps, tables, TV, sofas, pans and pots, patio furniture, BBQ, bikes, skates and others. - There is a 13,150.00 CAD Provincial Exemption on furniture and appliances

Living Room

Estimated Auction Value

Kitchen

Estimated Auction Value

Study

Estimated Auction Value

Bedrooms

Estimated Auction Value

Dining Room

Estimated Auction Value

Family room

Estimated Auction Value

Outdoor

Estimated Auction Value

Total Furniture and Appliances Estimated Auction Value

Personal Effects

Please add the estimated value you think your personal effects could be sold for in an auction. This includes cell phones, computers, tablets, video games, musical instruments and others. - There is a 5.650.00 CAD Provincial Exemption on furniture and appliances

List

Please list and describe any personal effect you have that might be auctionable.

Total Personal Effects Estimated Auction Value

Estimated Auction Value

Insurances, funds, stocks, shares and bonds and TFSA

Life Insurance

Name of insurance carrier, type of insurance (term, whole life) Policy #, Beneficiary(s) and relationship to you

Total Insurance Cash Surrender Value

Mutual Funds

Name of securities company – Plan #

Total Mutual Funds Cash Surrender Value

Stocks and Bonds

Company name and # of shares held

Total Stocks and Bonds Cash Surrender Value

Credit Union Shares

Name of Credit union and branch address

Total Credit Union Shares Cash Surrender Value

TFSA

Company name and plan number

Total TFSA Cash Surrender Value

Accounts Receivable/Money owed to you

Name and address of person/entity owing you money

Total Receivable/Money owed Value

Vehicles and Real Estate

Automobiles

Year

Make

Model

Trim (i;e; LS)

VIN #

Exterior Color

Interior Color

Nº of kms

Motorcycles

Year

Make

Model

Trim (i;e; LS)

VIN #

Exterior Color

Interior Color

Nº of kms

Snowmobiles

Year

Make

Model

Trim (i;e; LS)

VIN #

Exterior Color

Interior Color

Nº of kms

Recreational Vehicles

Year

Make

Model

Trim (i;e; LS)

VIN #

Exterior Color

Interior Color

Nº of kms

Other Motorized Vehicles

Year

Make

Model

Trim (i;e; LS)

VIN #

Exterior Color

Interior Color

Nº of kms

Total Vehicles Auction Value

Real Estates

Municipal address, City, Province

Jointly Owned? Mark if yes

Total Real Estate Auction Value

Tools of Trade

List all tools that belong to you and that are used to generate income.

List of tools

Please include a description of the tool (what it is, condition, year of manufacture and others).

Total Tools of Trade Auction Value

Jewelry and Collections

List of jewelry

Please include a description of the jewel (what it is, condition, year of manufacture and others).

Total Jewelry Auction Value

List of Collectionables

Please include a description of the items (what it is, condition, year of manufacture and others).

Total Collection Auction Value

Are any appraisals available to support your valuations of assets?

Yes

If yes, give details

Are your assets insured?

Yes

If yes, with whom?

Does your husband/wife own any assets jointly with you?

Yes

If yes, give details

TOTAL AUCTION VALUE

Real Estate Liabilities (Debt)

Do you own real estate?

Yes

Real Estate #1

Name of Mortgagor

Address

Amount

Maturity Date

List first, second and third mortgage (if applicable) holder's name, address, amount and maturity date for Real Estate # 1:

If Real Estate # 1. has joint ownership, list the other owners and percentage of each interest:

Real Estate #2

Name of Mortgagor

Address

Amount

Maturity Date

List first, second and third mortgage (if applicable) holder's name, address, amount and maturity date for Real Estate # 2:

If Real Estate # 2. has joint ownership, list the other owners and percentage of each interest:

Real Estate #3

Name of Mortgagor

Address

Amount

Maturity Date

List first, second and third mortgage (if applicable) holder's name, address, amount and maturity date for Real Estate # 3:

If Real Estate # 3. has joint ownership, list the other owners and percentage of each interest:

Are there any writs or judgments that are registered against any real estate property?

Yes

If yes, give details:

(name, court action #, amount)

Liabilities (Debts)

SECURED CREDITORS (Assets pledged against the loan) LIST NOT INCLUDING REAL ESTATE:

Under "TYPE OF DEBT" Please indicate J - joint debt, H - husband debt, or W - wife only debt

Under “TYPE OF SECURITY” Please indicate Car Loans, Chattel Mortgages, Leases, Conditional Sales Contract

PLEASE INSURE THAT COMPLETE ADDRESSES, POSTAL CODES AND ACCOUNT NUMBERS ARE LISTED.

Debts

Type of Debt

Complete name of original creditor

Complete address of original creditor

Postal Code

Acct Number

Type of Security

Amount Owed

Total Secured Creditors

Within the last 12 months, have you executed a chattel mortgage (movable property such as vehicles, ATVs and similar)or pledged any of your property?

Yes

If yes, give details:

Credit Card List

Credit Cards

Issuer of Card

Account Number

Card Type

Status (Up to date or Arrears)

Credit Limit

Monthly Payments

Balance Owed

Total amount owed for

UNSECURED CREDITORS LIST NOT INCLUDING CREDIT CARDS:

PLEASE INSURE THAT COMPLETE ADDRESSES, POSTAL CODES AND ACCOUNT NUMBERS ARE LISTED.

(Under "TYPE OF DEBT" Please indicate J - joint debt, H - husband debt, or W - wife only debt)

Other Unsecured Debts (ie Line of Credit, Payday Loan)

Type of Debt

Complete name of original creditor

Complete address of original creditor

Postal Code

Acct Number

Type of Security

Amount Owed

Total Unsecured Creditors not including Credit Cards

Has anyone co-signed or guaranteed a loan for you?

Yes

If yes, give details: Type of Debts co-signed or guaranteed

Business

Personal

Both

Guaranteed Loans

Lender's Name & Address

Amount of Loan

Borrower's Name & Address

Is Borrower Bankrupt?

Business/ Personal

Type of Business

Monthly Income

List all income earned by Debtor and Spouse.

Sources of income for Debtor and Spouse

Employment Inc. after Statutory ded.

E.I. Inc.

CPP Inc.

OAS Inc.

Company Pension Inc.

RIF Inc.

LIF Inc.

Canada Child Benefit

Child Support Inc.

Spousal Support Inc.

WSIB

Disability Benefits Inc.

Insurance Benefits

Social Assistance

Gov’t Rebate -Trillium

Gov’t Rebates – HST/GST

Rent/Board Rec’d

Self Employed

Investment Inc.

Other Inc

Employment Inc. after Statutory ded.

E.I. Inc.

CPP Inc.

OAS Inc.

Company Pension Inc.

RIF Inc.

LIF Inc.

Canada Child Benefit

Child Support Inc.

Spousal Support Inc.

WSIB

Disability Benefits Inc.

Insurance Benefits

Social Assistance

Gov’t Rebate -Trillium

Gov’t Rebates – HST/GST

Rent/Board Rec’d

Self Employed - Gross

Self Employed - Net

Investment Inc.

Other

List other income

Debtor and Spouse's Total Monthly Income

Household Expenses

Monthly Expenses

Rent/Mortgage

Property Taxes/Condo

Heating Gas/Oil

Telephone

Cable T.V.

Hydro

Water

Furniture

Tobacco

Alcohol

Dining out/Lunches

Coffee

Sports/Entertainment

Entertainment

Gifts/Donations

Newspaper/Magazine

Bank fees

Gambling-Lotto/Bingo

Allowances/Child

Internet

Prescriptions

Dental/Eye Care

Groceries

Laundry/Dry Cleaning

Grooming (Salon/Barber)

Clothing

Auto lease/pmts

Gas/Oil (auto)

Auto repair/upkeep

Transit/Taxi

Parking/Car Pool

Auto - other

Auto ins./License

Home insurance

Life insurance

Insurance - other

Spouse’s debt pmt(s)

Child support pmt(s)

Child care/Day care

Spousal support pmts

Medical Condition Exp.

Fines/Penalties

Employment Expenses

Other

Rent/Mortgage

Property Taxes/Condo

Heating Gas/Oil

Telephone

Cable T.V

Hydro

Water

Furniture

Tobacco

Alcohol

Dining Out/Lunches

Coffee

Sports/Entertainment

Gifts/Donations

Newspaper/Magazine

Bank Fees

Gambling-Lotto/Bingo

Allowances/Child

Internet

Prescriptions

Dental/Eye Care

Groceries

Laundry/Dry Cleaning

Grooming (Salon/Barber)

Clothing

Auto Lease/Payments

Gas/Oil (auto)

Auto Repair/Upkeep

Transit/Taxi

Parking/Car Pool

Auto Insurance/License

Home Insurance

Insurance (Other)

Spouse's debt payments

Child support payments

Child care/Day care

Spousal Support payments

Medical Condition Expenses

Fines/Penalties

Employment Expenses

Other

List other expenses

Total Monthly Expenses

Supplementary

Have you co-signed or guaranteed a loan or contract for anyone else or any business that has not been fully repaid?

Yes

If yes, give details: Type of Debts co-signed or guaranteed

Business

Personal

Both

Guaranteed Loans

Lender's Name & Address

Amount of Loan

Borrower's Name & Address

Is Borrower Bankrupt?

Business/ Personal

Type of Business

Are you in possession of or storing any personal property which does NOT belong to you? Example: household goods, motor vehicles, or other property?

Yes

If yes, give details

Have you received or do you expect to receive an inheritance during the next 12 months?

Yes

If yes, give details

Have you been or are you presently involved in any civil litigation involving yourself, your spouse, or any business venture present or past?

Yes

If yes, give details

name, address, court number, date started, amount:

Within the last five years have you:

Pledged any property to anyone?

Yes

If yes, give details

Pledged additional security to any of your creditors after the initial transaction?

Yes

If yes, give details

Been party to any insurance or matrimonial settlement?

Yes

If yes, give details

Has any of your creditors commenced Court action against you for debts owed? (i.e. wage garnishment, third party demands)?

Yes

If yes, give details

Have you obtained any credit in the last three months?

Yes

If yes, give details

Is there any property registered in your name for insurance purposes only?

Yes

If yes, give details

Date of Assessment (when you finish filling this form)(Required)

MM slash DD slash YYYY

Location of Assessment (where you completed this form)(Required)

City State / Province / Region

Consent(Required)

This information provided by me is accurate to the best of my knowledge.

Supportive Documentation

Drop files here or

Max. file size: 128 MB.

Please upload a copy of your Driver's License, Birth Certificate, Passport, Citizenship Card/Certificate, Vehicle Insurance and Ownership, most current Pay Stub, Mortgage Statements (if applicable), VOID cheque and any other documents you deem relevant.

Untitled

First Choice

Second Choice

Third Choice

We can help you determine whether a consumer proposal is right for you

A Consumer Proposal is your Chance
for a Fresh Start.

Call for a free and confidential consultation at

1-800-665-9965

Book an Appointment

Intake Form

Assessment / Intake Form

Debtor

Personal Information

Contact Information

Income Sources

Job #2

Employment History

Debtor's Business Involvement

Business 1

Business 2

Bankruptcy History

Tax Returns

Debtor's Spouse/Partner

Spouse/Partner - Contact Information

Spouse/Partner's Information

Spouse/Partner's - Job #2

Spouse/Partner - Employment History

Spouse/Partner's Business Involvement

Bankruptcy History

Tax Returns

Circumstances causing financial problems

Dependants

Alimony / Maintenance

Self Employed Business Operating Budget Information

Supplementary Information

Within the last 12 months, have you…

Within the last 5 years, have you....

Have you any debts arising from....

Residential Rental Information

Assets

Cash in hand

Financial Institutions

Furniture and Appliances

Personal Effects

Insurances, funds, stocks, shares and bonds and TFSA

Vehicles and Real Estate

Tools of Trade

Jewelry and Collections

Real Estate Liabilities (Debt)

Liabilities (Debts)

Credit Card List

Monthly Income

Household Expenses

Supplementary

A Consumer Proposal is your Chance for a Fresh Start.

Professional Accreditation

A Consumer Proposal is your Chance
for a Fresh Start.