Fillable Printable Statement of Affairs Sample Form
Fillable Printable Statement of Affairs Sample Form
Statement of Affairs Sample Form
FORM 79
Statement of Affairs (Non-Business Bankruptcy/Proposal)
(Subsections 49(2) and 158(d) of the Act / Subsections 50(2) and 62(1) and Paragraph 66.13(2)(d) of the Act)
(Title Form 1)
□ Original □ Amended
ASSETS
Exempt property Type of assets Description (provide
details)
Estimate
dollar
value
Yes No
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, RRSPs, etc.
5. Securities
6. Real property or
immovables
House
Cottage
Land
7. Motor vehicle Automobile
Motorcycle
Snowmobile
Other
8. Recreational equipment
9. Estimated tax refund
10. Other assets
TOTAL
________________________ _____________________________
Date Bankrupt/Debtor
*For a summary administration, indicate value net of the direct realization costs referred to in Rule 128(1) of the Bankruptcy and Insolvency Act .
FORM 79 -- Continued
LIABILITIES
Liabilities type code (LTC)
1 Real property or immovable mortgage or hypothec
2 Bank loans (except real property mortgage)
3 Finance company loans
4 Credit cards - bank/trust company issuers
5 Credit cards - other issuers
6 Taxes - federal/provincial/municipal
7 Student loans
8 Loans from individuals
9 Other
Amount of debt Creditor Address, including postal
code
Account
No.
Unsecured Secured Preferred
Enter
LTC
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
TOTAL Unsecured
TOTAL Secured
TOTAL Preferred
__________________________ _________________________
Date Bankrupt/Debtor
FORM 79 -- Continued
A. INFORMATION RELATING TO THE AFFAIRS OF THE BANKRUPT/DEBTOR
Given names: 1. Family name:
Gender: F □ M □
Date of birth: / /
YYYY/ MM / DD
2. Also known as:
3. Complete address, including postal code:
Married
Single
Widowed
Separated
4. Marital status:
(specify month and year of event if it
occurred in the last five years)
Divorced
Common-law
partner
5. Full name of spouse or common-law partner:
6. Name of present employer: Occupation (bankrupt/debtor):
7A. Number of persons in household family unit, including bankrupt/debtor:
7B. Number of persons 17 years of age or younger:
8. Have you operated a business
within the last five years?
Yes No (If yes) Name, type and period
of operation:
B. WITHIN 12 MONTHS PRIOR TO THE DATE OF THE INITIAL BANKRUPTCY EVENT,
HAVE YOU, EITHER IN CANADA OR ELSEWHERE:
9A. Sold or disposed of any of your property? Yes No
9B. Made payments in excess of the regular payments to creditors? Yes No
9C. Had any property seized by a creditor? Yes No
C. WITHIN FIVE YEARS PRIOR TO THE DATE OF THE INITIAL BANKRUPTCY EVENT,
HAVE YOU, EITHER IN CANADA OR ELSEWHERE:
10A. Sold or disposed of any property? Yes No
10B. Made any gifts to relatives or others in excess of $500? Yes No
_______________________ ____________________________
Date Bankrupt/Debtor
FORM 79 -- Concluded
D. BUDGET INFORMATION: Attach Form 65 to this form
11A. Have you ever made a proposal under the Bankruptcy and Insolvency Act? Yes No
11B. Have you been bankrupt before in Canada? Yes No
(If yes, provide the following details for all insolvency proceedings: (a) filing date and location of the
proceedings; (b) name of trustee or administrator; (c) if applicable, was the proposal successful; (d) date on which
Certificate of Full Performance or Discharge was obtained.)
12. Do you expect to receive any sums of money that are not related to your normal income, or any other property
within the next 12 months? Yes
No
13. If you answered Yes to any of questions 8, 9 or 11, provide details:
14. Give reasons for your financial difficulties:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
I, ________________, of the __________ of ____________________ in the Province of ________________,do
swear (or solemnly declare) that this statement is, to the best of my knowledge, a full, true and complete statement
of my affairs on the ______ day of _________ ______ and fully discloses all property and transactions of every
description that is or was in my possession or that may devolve on me in accordance with the Bankruptcy and
Insolvency Act.
SWORN (or SOLEMNLY DECLARED)
before me at ______________________________ (city, town or village),
in the Province of __________________________,
on this ____ day of _______________ _________.
___________________________ ____________________________
Commissioner of Oaths Bankrupt/Debtor
for the Province of _________________________
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.
