New Client Intake Form

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Please fill this form with the most accurate information to the best of your knowledge, and upload all the appropriate supportive documentation with it. If you have ANY questions while you are filling this form, please give us a call at 800-665-9965.

Step 1 of 19

Client 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 (also known as)? If so what names?

Current marital status(Required)

Married

Single

Widower

Widowed

Common Law

Separated

Divorced

Do you pay or have paid Alimony/Spousal Support?(Required)

Yes

Date of Marriage/Separation/Divorce if applicable(Required)

DD slash MM slash YYYY

Do you have a Separation Agreement?(Required)

Yes

Please attach your copy of agreement(Required)

Max. file size: 2 GB.

Do you have a Court Order (Under Family Law)(Required)

Yes

Please attach your copy of the order(Required)

Max. file size: 2 GB.

Do you have a Prenuptial Agreement?(Required)

Yes

Please attach your copy of agreement

Max. file size: 2 GB.

S.I.N(Required)

Birthdate(Required)

DD slash MM slash YYYY

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

Contact Information

Home Phone

Mobile phone

Fax

Work Phone

Messages

Home Address

Street Address Address Line 2 City Province Postal Code

Length of time at this residence

You have resided at this residence since

DD slash MM slash YYYY

Previous Adresseses

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:

Alternate Contact Name (Person not living at the same residence)(Required)

First Last

Needed if we lose contact that we can leave a message with for you to contact our office. No details will be provided to alternate contact other than you to call our office.

Alternate Contact Phone(Required)

Relationship to debtor(Required)

Sources of Income

Current employment situation

Employed

Unemployed

Self-Employed

Two jobs

Part-time

Retired

Occupation

Employer's name

Employer's Address

Street Address Address Line 2 City Province Postal Code

Phone No. of Employer

Fax No. of Employer

Employed since

DD slash MM slash YYYY

Are you bonded in your present job?

Yes

Date

MM slash DD slash YYYY

Name of Company paying Pension benefits (other than CPP or OAS)

What is the name of the company paying the pension? (do not fill if you are collecting CPP and OAS)

Address of Company Paying the Pension

Street Address Address Line 2 City Province Postal Code

What is the address of the company paying the pension? (do not fill if you are collecting CPP and OAS)

Fax Number of The Company

What is the fax number of the company paying the pension? (do not fill if you are collecting CPP and OAS)

Job #2

Job #2 - Occupation

Job #2 - Employer's name

Job #2 - Employer's Address

Street Address Address Line 2 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 filing is joint, list spouse's employers/EI also, and mark with "S" in the far right column.

History

Employer's Name

Address

Started

Ended

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

EI benefits start date

DD slash MM slash YYYY

EI benefits ceased date

DD slash MM slash YYYY

Which office granted E.I. benefit?

Business Involvement

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

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

Yes

Self-employed would include a partnership or if you are the majority owner of a corporation

Are any of the debts business debts?

Yes

Approximately what percentages of the debts are from business?

Business 1 - Business Name

Business 1 - Start Date

DD slash MM slash YYYY

Business 1 - Address

Street Address Address Line 2 City Province Postal Code

Business 1 - Type of Business

Business 1 - Business still operating?

Yes

Business 1 - Date ceased to operate

DD slash MM slash YYYY

Business 1 - Sole Proprietorship

Yes

Business 1 - Partnership

Yes

Business 1 - If yes, names of partners

Partner 1

Partner 2

Business 1 - Percentage for each partner:

Self %

Partner 1 %

Partner 2%

Business 1 - Corporation

Yes

Business 1 - Date incorporated

DD slash MM slash YYYY

Business 1 - When is/was fiscal year end?

Business 1 - Corporate Tax Number

Business 1 - GST/HST No.

Business 1 - Have you guaranteed any business loans?

Yes

Business 1 - Give details of business 1 guarantees

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

Do you or did you operate a 2nd business?

Yes

Business 2 - Business Name

Business 2 - Start Date

DD slash MM slash YYYY

Business 2 - Address

Street Address Address Line 2 City Province Postal Code

Business 2 - Type of Business

Business 2 - Business still operating?

Yes

Business 2 - When did it cease to operate

DD slash MM slash YYYY

Business 2 - Sole Proprietorship

Yes

Business 2 - Partnership

Yes

Business 2 - Names of partners

Partner 1 Name

Partner 2 Name

Business 2 - Percentage for each partner:

Self %

Partner 1 %

Partner 2 %

Business 2 - Corporate Tax Number

Business 2 - GST/HST No.

Business 2 - Have you guaranteed any business loans?

Yes

Business 2 - Guarantees for Business 2, Provide details

Business 2 - When is/was fiscal year end?

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

Are you now an officer or director, or involved in any managerial capacity in any corporation?

Yes

If so, give the name of the company, your title or position and date you started.

Company Name

Your Title/Position

Date 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?

Yes

If so, give the name of the company, your title or position and details of the bankruptcy or proposal.

Company Name

Your Title/Position

Date Started

Details

Insolvency History

Have you ever been bankrupt before?

Yes

How many bankruptcies?

Please enter a number from 1 to 3.

1st Bankruptcy - Filed under what Full name?

1st bankruptcy - Reasons

Please be as detailed as possible as to the cause of the previous bankruptcy.

2nd Bankruptcy - Filed under what Full name?

2nd bankruptcy - Reasons for having filed

Please be as detailed as possible as to the cause of the previous bankruptcy.

Have you ever filed a proposal to your creditors before?

Yes

How many proposals have be filed?

Please enter a number from 1 to 3.

1st Proposal - Filed under what Full name?

1st Proposal - Reasons for filing

Please be as detailed as possible as to the cause of the previous proposal.

2nd Proposal - Filed under what Full name?

2nd Proposal - Reasons for filing

Please be as detailed as possible as to the cause of the 2nd proposal.

Tax Returns

For which year was your last tax return filed?

What is the amount shown on the 15000 line on your tax assessment?

Input it in $

Refund Received?

Yes

Approximately how much was the refund?

Refund to come?

Yes

Approximately how much is expected?

Amount Owed to Canada Revenue Agency (CRA)

Your address where you were living when you filed that return?

Street Address Address Line 2 City Province Postal Code

Have you filed prior year's income tax returns?

Yes

Years not filled

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

Yes

Debtor's Spouse/Partner

Spouse/Partner - Personal Information

Spouse/Partner - Full legal name (As on your Birth Certificate / Passport / Citizenship Card)

First Middle Last

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

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

Spouse/Partner - Date of Separation/Divorce if applicable

DD slash MM slash YYYY

Spouse/Partner - S.I.N

Spouse/Partner - Birth date

DD slash MM slash YYYY

Spouse/Partner - 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 - Contact Information

Spouse/Partner - Cell No.

Spouse/Partner - Work Phone

Spouse/Partner - Messages

Spouse/Partner - Email

Spouse/Partners - 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:

Spouse/Partner - Alternate Contact

Name

Phone

Relationship to Debtor

Not living at the same residence

Spouse/Partner's - Source(s) of Income

Spouse/Partner - Current employment situation

Employed

Unemployed

Self-Employed

Two jobs

Part-time

Retired

Spouse/Partner - Occupation

Spouse/Partner - Employer's name

Spouse/Partner - Employer's Address

Street Address Address Line 2 City Province Postal Code

Spouse/Partner - Employers Phone Number

Spouse/Partner - Employers Fax Number

Employed since

DD slash MM slash YYYY

Are you bonded in your present job?

Yes

Spouse/Partner - Name of Company Paying The Pension

What is the name of the company paying the pension? (do not fill if you are collecting CPP and OAS)

Spouse/Partner - Address of The Company Paying The Pension

Street Address Address Line 2 City Province Postal Code

What is the address of the company paying the pension? (do not fill if you are collecting CPP and OAS)

Phone Number of The Company

What is the phone number of the company paying the pension? (do not fill if you are collecting CPP and OAS)

Fax Number of The Company

What is the fax number of the company paying the pension? (do not fill if you are collecting CPP and OAS)

Spouse/Partner - Job #2

Spouse/Partner - Job #2 - Occupation

Spouse/Partner - Job #2 - Employer's name

Spouse/Partner - Job #2 - Employer's Address

Street Address Address Line 2 City Province Postal Code

Spouse/Partner - Job #2 - Employed since

DD slash MM slash YYYY

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

Yes

Spouse/Partner - 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.

Spouse/Partner - Employment History

Employer's Name

Address

Started

Ended

Click on the+ sign to add additional employers.

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

Spouse/Partner - EI benefits start date

DD slash MM slash YYYY

Spouse/Partner - EI benefits ceased date

DD slash MM slash YYYY

Spouse/Partner - Which office granted E.I. benefit?

Spouse/Partner - Business Involvement

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

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

Yes

Spouse/Partner - Are any of the debts business debts?

Yes

Spouse/Partner - What percentages of the debts are from business?

Spouse/Partner - Business 1 - Name and start date

Spouse/Partner - Business 1 Address

Street Address Address Line 2 City Province Postal Code

Spouse/Partner - Business 1 - Business Type

Spouse/Partner - Business 1 still operating?

Yes

Spouse/Partner - Business 1 - When did it cease to operate

DD slash MM slash YYYY

Spouse/Partner - Business 1 - Sole proprietorship?

Yes

Spouse/Partner - Business 1 - Partnership?

Yes

Spouse/Partner - Business 1 - Partner's names

Partner 1

Partner 2

Click on the+ sign to add additional employers.

Spouse/Partner - Business 1 - Percentage for each partner:

Self %

Partner 1 %

Partner 2 %

Spouse/Partner - Business 1 - Corporate Tax No.

Spouse/Partner - Business 1 - GST/HST No

Spouse/Partner - Business 1 - Have you guaranteed any business loans?

Yes

Spouse/Partner - Business 1 Guarantees - Provide details

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

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

Spouse/Partner - Business 2 - Name and Start date

Spouse/Partner - Business 2 - Address

Street Address Address Line 2 City Province Postal Code

Spouse/Partner - Business 2 - Type of Business

Spouse/Partner - Business 2 - Business still operating?

Yes

Spouse/Partner - Business 2 - If no, when did it cease to operate

DD slash MM slash YYYY

Spouse/Partner - Business 2 - Sole proprietorship?

Yes

Spouse/Partner - Business 2 - Partnership?

Yes

Spouse/Partner - Business 2 - Partner's names

Partner 1

Partner 2

Click on the+ sign to add additional employers.

Spouse/Partner - Business 2 - Percentage for each partner:

Self %

Partner 1 %

Partner 2 %

Click on the+ sign to add additional employers.

Spouse/Partner - Business 2 - Corporate Tax No.

Spouse/Partner - Business 2 - GST/HST No.

Spouse/Partner - Business 2 - Have you guaranteed any business loans?

Yes

Spouse/Partner - Business 2 - Guarantees give details

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

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

Spouse/Partner - Business 2 - 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.

Spouse/Partner - Business 2 - 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.

Spouse/Partner - Bankruptcy History

Spouse/Partner - Have you ever been bankrupt before?

Yes

Spouse/Partner - How many times have you filed for bankrupty?

Please enter a number from 1 to 3.

Spouse/Partner - 1st Bankruptcy - Filed under what Full name?

Spouse/Partner - 1st bankruptcy - Reasons

Please be as detailed as possible as to the cause of the previous bankruptcy.

Spouse/Partner - 2nd Bankruptcy - Filed under what Full name?

Spouse/Partner - 2nd bankruptcy - Reasons

Please be as detailed as possible as to the cause of the previous bankruptcy.

Spouse/Partner - Have you ever filed a proposal to your creditors before?

Yes

Spouse/Partner - How many proposals have be filed?

Please enter a number from 1 to 3.

Spouse/Partner - 1st Proposal - Filed under what Full name?

Spouse/Partner - 1st Proposal - Reasons for filing

Please be as detailed as possible as to the cause of the previous proposal.

Spouse/Partner - 2nd Proposal - Filed under what Full name?

Spouse/Partner - 2nd Proposal - Reasons for filing

Please be as detailed as possible as to the cause of the previous proposal.

Spouse/Partner - Tax Returns

Spouse/Partner - For which year was your last tax return filed?

What was the amount under line 1500 on the Tax Assessment?

Spouse/Partner - Refund Received?

Yes

Spouse/Partner - Refund to come?

Yes

Spouse/Partner - Amount Owed

Spouse/Partner - Taxes Paid

Spouse/Partner - Address when you filed that return?

Street Address Address Line 2 City Province Postal Code

Have you filed prior year's income tax returns?

Yes

Spouse/Partner - Years not filed

Spouse/Partner - Did you register/qualify for GST rebate?

Yes

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

Click on the+ sign to add additional dependents.

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

Alimony/Spousal Maintenance

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

Name

First Last

Address

Street Address Address Line 2 City Province Postal Code

Monthy Amount Paid

Arrears Amount

Self Employed Business Operating Budget Information

Self-Employed Gross Income

Source of Income

List sources of income

Total Monthly Net Income

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

Estimated Yearly Auto Maintenance and repairs

Monthly Auto Maintenance and repairs

Automatically calculated

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

Please list additional expenses

Total Monthly Expenses

Total Monthly Net Income

Calculated automatically for you

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 (pledged any assets)?

Yes

To Whom

When

DD slash MM slash YYYY

What

Why

To Whom

When

DD slash MM slash YYYY

What

Why

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

Sold, disposed of or transferred any real estate?

Yes

Address of Property

Street Address Address Line 2 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

If yes, please explain

Recognizance or bail?

Yes

If yes, please explain

Fraud?

Yes

If yes, please explain

Misappropriation?

Yes

If yes, please explain

Maintenance & support of separated family?

Yes

If yes, please explain

Alimony?

Yes

If yes, please explain

Defalcation while acting in a fiduciary capacity?

Yes

If yes, please explain

Embezzlement?

Yes

Embezzlement - please explain

Obtained property by false pretense or fraudulent misrepresentation?

Yes

If yes, please explain

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

Yes

Do not understand

If yes, give details

Have you given an assignment of your wages to anyone?

Yes

If yes, give details

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

Yes

If yes, give details

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

Yes

If yes, give details

Circumstances causing financial problems

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

Spouse/Partner - Circumstances causing financial problems

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

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/coins or digital currency)

Currency

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

Financial Institutions (Banks)

Money on deposit with Banks/Credit Unions/Money Markets/Cryptocurrency

Name of Bank/Credit Union/Money Markets/Cryptocurrency

Branch Address

Transit No & Account No (available on cheque)

Current Balance

Account Holder (A - Applicant, P - Partner)

Click on the+ sign to add additional fields.

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 Provincial Exemption on furniture and appliances

List

Please list and describe any personal effect you have that might be auctionable that would exceed the Provincial Exemption of $5,650.00.

Total Personal Effects Estimated Auction Value

Estimated Auction Value

Insurances, funds, stocks, shares and bonds and TFSA

Life Insurance

Name of company

Type of Insurance (term/whole life)

Policy No.

Beneficiary(s)

Relationship to applicant

Total Insurance Cash Surrender Value

Mutual Funds

Name of company

Plan No.

Amount

Total Mutual Funds Value

Stocks and Bonds

Name of company

No. of shares held

Amount

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

Click on the + sign to add additional fields.

Automobiles

Year

Make

Model

Trim (i.e. LS, EX)

VIN #

Exterior Colour

Interior Colour

No. of kms

Approx. value

Motorcycles

Year

Make

Model

Trim (i.e. Softail, Sportster)

VIN #

Exterior Colour

No. of kms

Approx. value

Snowmobiles

Year

Make

Model

Trim (i.e. Venture)

VIN #

Exterior Colour

No. of hours

Approx. value

Recreational Vehicles (i.e. ATVs)

Year

Make

Model

Trim (i.e. LS)

VIN #

Exterior Colour

Interior Colour

No. of kms

Approx. value

Other Motorized Vehicles (i.e. Riding Lawnmowers)

Year

Make

Model

Trim (i.e. LS)

VIN #

Exterior Colour

Interior Colour

No. of kms

Approx. vaule

Total Vehicles Auction Value

Real Estates

Municipal address, City, Province

Jointly Owned? If so, wtih whom.

Total Estimated Real Estate Value

Tools of Trade

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

List of Tools of Trade

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 partner 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 of Mortgage

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 of Mortgage

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 of Mortgage

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

Writs, Judgments - 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.

SECURED CREDITORS

SECURED CREDITORS (Assets pledged against the loan) LIST NOT INCLUDING REAL ESTATE: Under "TYPE OF DEBT" Please indicate J - joint debt, A - applicant debt, or S - spouse/partner only debt , J - joint 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.

Debt Type (A,S,J)

Creditor Name

Creditor address

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

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)

UNSECURED CREDITORS - (i.e. Line of Credit, Payday Loans) - NOT CREDIT CARDS will be dealt with later in the form below

UNSECURED CREDITORS (No assets have been been against the loan) LIST NOT INCLUDING REAL ESTATE: Under "TYPE OF DEBT" Please indicate J - joint debt, A - applicant debt or S - spouse/partner debt. PLEASE INSURE THAT COMPLETE ADDRESSES OF CREDITORS AND ACCOUNT NUMBERS ARE LISTED.

Type of Debt (J or A or S)

Creditor Name

Creditor address

Acct Number

Approx. Amount Owed

Total Unsecured Creditors (Not including Credit Cards)

If yes, give details:

CREDIT CARDS

Credit Cards

Issuer of Card

Account Number

Card Type (i.e. Gold)

Status (Up to date or Arrears)

Credit Limit

Monthly Payments

Balance Owed

Total credit card debt

Total Debt owed $

Automatically calculated

Total number of creditors

Automatically calculated

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

Loans Guaranteed

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

Sources of income(Required)

Employment Inc. after Statutory ded.

Self Employed

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. (Ontario)

Disability Benefits (Canada)

Insurance Benefits

Social Assistance

Gov’t Rebate (Trillium)

Gov’t Rebates (HST/GST)

Rent/Board Rec’d

Dividend Inc.

Interest Income

Other Income

Climate Change Benefit

No income

Monthly Employment income after statutory deductions (CPP, EI, Taxes, Union dues, RPP)

Self Employed - Gross

Self Employed - Net

Employment Insurance (E.I.) Inc.

Canada Pension Plan (CPP) income

Old Age Security (OAS) income

Company Pension income

Registered Income Fund (RIF) income

Life Income fund (LIF) income

Name of The Company Paying The Benefit

Address of the Company Paying The Benefit

Street Address Address Line 2 City Province Postal Code

Phone of The Company Paying The Benefit

Fax Number of The Company Paying The Benefit

Canada Child Benefit

Child Support income

Spousal Support income

WSIB benefits

Insurance benefits

Disability benefits (Ontario)

Disability benefits (Canada)

Social assistance benefits (Ontario Works)

Monthly Gov’t rebates (Trillium)

Climate Change Benefit (monthly)

Quarterly Gov’t rebates payment (i.e. HST/GST)

Monthly Gov’t rebates (i.e. HST/GST)

Automatically calculated

Rent/Board received

Dividend income

Interest income

Other income

List other income

Total Monthly income

Spouse/Partner - Sources of income

Employment Inc. after Statutory ded.

Self Employed

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. (Ontario)

Disability Benefits (Canada)

Insurance Benefits

Social Assistance

Gov’t Rebate - Trillium

Gov’t Rebates (HST/GST)

Rent/Board Rec’d

Dividend Inc.

Interest Income

Other income

Climate Change Benefit

No income

Spouse/Partner - Monthly Employment income after statutory deductions (CPP, EI, Taxes, Union dues, RPP)

Spouse/Partner - Self Employed - Gross income

Spouse/Partner - Self Employed - Net income

Spouse/Partner - Employment insurance (E.I.) benefits (Net)

Spouse/Partner - Canada Pension Plan (CPP) income

Spouse/Partner - Old Age Security (OAS) income

Spouse/Partner - Company Pension income

Spouse/Partner - Registered Income Fund (RIF) income

Spouse/Partner - Life Income fund (LIF) income

Spouse/Partner - Name of The Company Paying The Benefit

Spouse/Partner - Address of the Company Paying The Benefit

Street Address Address Line 2 City Province Postal Code

Spouse/Partner - Phone of The Company Paying The Benefit

Spouse/Partner - Fax Number of The Company Paying The Benefit

Spouse/Partner - Canada Child Benefit

Spouse/Partner - Child Support Income

Spouse/Partner - Spousal Support Income

Spouse/Partner - WSIB

Spouse/Partner - Insurance Benefits

Spouse/Partner - Disability Benefits Inc. (Ontario)

Spouse/Partner - Disability Benefits Inc. (Canada)

Spouse/Partner - Social Assistance (Ontario Works)

Spouse/Partner - Gov’t Rebate (Trillium)

Spouse/Partner - Climate Change Benefit

Spouse/Partner - Quarterly Gov't Rebates pmt. (HST/GST)

Spouse/Partner - Gov’t Monthly Rebates (HST/GST)

Automatically Calculated

Spouse/Partner - Gov’t Rebates (HST/GST)

Spouse/Partner - Rent/Board Received

Spouse/Partner - Dividend Income

Spouse/Partner - Interest Income

Spouse/Partner - Other income

Spouse/Partner - List other income

Spouse's Total Monthly income

Household Expenses

Monthly Expenses(Required)

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

The amount section will be displayed in the section below after you have checked off the categories of spending

Rent/Mortgage(Required)

Property Taxes/Condo(Required)

Heating Gas/Oil(Required)

Telephone(Required)

Cable/Satellite T.V(Required)

Hydro(Required)

Water(Required)

Furniture Expenses/Purchases(Required)

Yearly estimate

Furniture Expenses/Purchases

automatically calculated

Tobacco/Cannabis(Required)

Alcohol(Required)

Dining Out/Lunches(Required)

Coffee(Required)

Sports/Entertainment Expenses(Required)

Yearly estimate

Monthly Sports/Entertainment Expenses

Automatically Calculated

Gifts/Donations(Required)

Yearly estimate

Monthly Gifts/Donations

Automatically calculated

Newspaper/Magazine(Required)

Bank Fees(Required)

Gambling-Lotto/Bingo(Required)

Allowances/Child(Required)

Internet(Required)

Prescriptions(Required)

Dental/Eye Care Expenses(Required)

Yearly Estimate

Yearly Dental/Eye Care Expenses(Required)

Automatically calculated

Groceries(Required)

Laundry/Dry Cleaning(Required)

Grooming (Salon/Barber)(Required)

Yearly Clothing Expenses(Required)

Automatically calculated

Auto Lease/Payments(Required)

Gas/Oil (auto)(Required)

Auto Repair/Upkeep Expenses(Required)

Yearly Estimate

Monthly Auto Repair/Upkeep Expenses(Required)

Automatically calculated

Transit/Taxi(Required)

Parking/Car Pool(Required)

Auto Insurance/License(Required)

Home Insurance(Required)

Insurance (Other)(Required)

Spouse's debt payments(Required)

Child support payments(Required)

Child care/Day care(Required)

Spousal Support payments(Required)

Medical Condition Expenses(Required)

Fines/Penalties(Required)

Employment Expenses (not reimbursed)(Required)

Other Expenses(Required)

List other expenses(Required)

Total Monthly Expenses

automatically calculated

Monthly Surplus/Deficit

This amount was automatically calculated by adding the Applicant's and the Applicant's Spouse's income and subtracting it from the Household Expenses.

Additional Questions

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.

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

File and document upload

Drop files here or

Max. file size: 2 GB.

If you are having problems making a digital copy of your documents, or if you would like to agree on a different type of document delivery, please send us an email at admin@danatrustee.ca or give us a call at 1 (800) 665-9965.

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

New Client Intake Form

Client Intake Form

Debtor

Personal Information

Contact Information

Sources of Income

Job #2

Employment History

Business Involvement

Insolvency History

Tax Returns

Debtor's Spouse/Partner

Spouse/Partner - Personal Information

Spouse/Partner - Contact Information

Spouse/Partner's - Source(s) of Income

Spouse/Partner - Job #2

Spouse/Partner - Employment History

Spouse/Partner - Business Involvement

Spouse/Partner - Bankruptcy History

Spouse/Partner - Tax Returns

Dependants

Alimony/Spousal 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....

Circumstances causing financial problems

Spouse/Partner - Circumstances causing financial problems

Residential Rental Information

Assets

Cash in hand

Financial Institutions (Banks)

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 CARDS

Monthly Income

Household Expenses

Additional Questions

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

A Consumer Proposal is your Chance for a Fresh Start.

Professional Accreditation

A Consumer Proposal is your Chance
for a Fresh Start.