DEBTOR INFORMATION Background Information Province * Please select… Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Country Please select… Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos ( Keeling ) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d ‘ Ivoire Croatia ( Hrvatska ) Cuba Cyprus Czech Republic Congo ( DRC ) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands ( Islas Malvinas ) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino São Tomé and Prìncipe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands ( British ) Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe
Postal Code A1A 1A1
How long have you lived at your current residence? (In years and months.) *
What is the total number of dependents living in the residence (including spouse)? * Please select… 1 2 3 4 5 6 7 8 9 10 11
How many children under 7 live at the residence? * Please select… 0 1 2 3 4 5 6 7 8 9 10
How many children under 17 live at the residence? * Please select… 0 1 2 3 4 5 6 7 8 9 10
If any dependants are over the age of 18, please explain why they are still a dependant.
Employment Information of Debtor Employment Status * Please select… Employed Unemployed
Please provide the date your unemployment began.
Month * Please select… Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Year * Please select… 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980
In the past 5 years have you operated a business? * Please select… Yes No
Is the business still operating? * Please select… Yes No
Describe the nature of the business. *
How long has the business been in operation? * Please select… 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years 26 Years 27 Years 28 Years 29 Years 30 Years
When did the business commence operation?
Please provide the date the business closed. *
What are the total debts due to the business? * $
How many employees are employed by the business? * Please select… 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Where is the location of the payroll register (please provide address)?
If you have any additional comments, please provide in the area provided.
Background Information of Spouse Is your spouse filing as well? Please select… Yes No
Do you live in same address as spouse? * Please select… Yes No
Employment Information of Spouse Employment Status * Please select… Employed Unemployed
Please provide the date when your spouse’s unemployment started.
Month * Please select… Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Year * Please select… 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980
At what time did your spouse begin employment with current employer?
Month * Please select… Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Year * Please select… 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980
In the past 5 years has your spouse operated a business? * Please select… Yes No
Is the business still operating? * Please select… Yes No
Describe the nature of the business. *
How long has the business been in operation? *
If the business is not operating anymore, please provide the date it closed. *
What are the total debts due to the business? * $
How many employees are employed by the business? *
Where is the location of the payroll register? (Please provide address.)
If you have any additional comments, please provide in the area provided.
Income Tax Information Please ensure that you provide Rumanek & Company with a copy of your last income tax return.
Have you filed an income tax return every year? Please select… Yes No
Last Year Tax Return Filed * Debtor Please select… 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980
Spouse Please select… 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980
Amount Owing Refund Received Refund Expected
Do you pay alimony or maintenance? Please select… Yes No
Do you rent or own your residence? * Please select… Rent Own Other
Do you own or rent your residence? * Please select… Rent Own Other
Provide Details
Prior Bankruptcy Have you (debtor) ever declared bankruptcy or a proposal in Canada or any other country? * Please select… Yes No
Has your spouse ever declared bankruptcy or a proposal in Canada or any other country? * Please select… Yes No
Did your spouse file a bankruptcy or proposal? * Please select… Bankruptcy Proposal
What year did the prior bankruptcy occur in? * Please select… 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980
What year did the prior proposal occur in? * Please select… 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980
Pertinent Information In the last 12 months, have you or your spouse withdrawn/cashed in any assets? * Please select… Yes No
In the last 12 months, have you withdrawn/cashed in any assets? * Please select… Yes No
Who has withdrawn/cashed in these assets? * Please select… Debtor Spouse Both
Excess Creditor Payments In the last 12 months, have you (debtor) or your spouse made any excess payments to creditors? * Please select… Yes No
In the last 12 months, have you (debtor) made any excess payments to creditors? * Please select… Yes No
Who made these excess payments? * Please select… Debtor Spouse Both
Please provide any details of these excess payments.
Seized Assets In the last 12 months, have you or your spouse had any assets seized by a creditor? * Please select… Yes No
In the last 12 months, have you had any assets seized by a creditor? * Please select… Yes No
Who’s assets were seized? * Please select… Debtor Spouse Both
Please provide any details of these seized assets.
Garnishment In the last 12 months, have you had any garnishments? * Please select… Yes No
In the last 12 months, have you or your spouse had any garnishments? * Please select… Yes No
Who was garnished? * Please select… Debtor Spouse Both
Please provide any details of what was garnished.
Real Estate In the last 5 years, have you or your spouse sold or disposed of any real estate? * Please select… Yes No
In the last 5 years, have you sold or disposed of any real estate? * Please select… Yes No
Who owned the property? * Please select… Debtor Spouse Joint
Please provide details of the disposition of funds.
Gifts in excess of $500 In the last 5 years, have you or your spouse made any gifts greater than $500 to relatives or other people? * Please select… Yes No
In the last 5 years, have you made any gifts greater than $500 to relatives or other people? * Please select… Yes No
Future Assets Do you expect to receive any sums of money which are not related to your normal income within the next 12 months? (e.g. insurance claims, law suits or pending settlements) * Please select… Yes No
Do you or your spouse expect to receive any sums of money which are not related to your normal income within the next 12 months? (e.g. insurance claims, law suits or pending settlements) * Please select… Yes No
Who is expecting the future asset? Please select… Debtor Spouse Both
Please provide details and include all relating documents *
Assets – RRSP/Stocks/Vehicles/Other Assets Cash Do you have a bank account? Please select… Yes No
Do you or your spouse have a bank account? Please select… Yes No
Life Insurance Please provide a copy of all policies.
Do you have a life insurance policy? * Please select… Yes No
Proprietorship Details What is the approximate value of your tools of trade? $
RRSPs, RESPs, Canada Savings Bonds, etc. Please provide documentation of all investments.
Do you or your spouse own any investments? * Please select… Yes No
Do you own any investments? * Please select… Yes No
Residential Property Investment Property Do you or your spouse have an investment property? * Please select… Yes No
Do you have an investment property? * Please select… Yes No
Motor Vehicles Do you or your spouse have a motor vehicle? * Please select… Yes No
Do you have a motor vehicle? * Please select… Yes No
Other Furniture, Appliances & Household Items
Approximate Value $
Summary of Items
Personal effects
Approximate Value $
Summary of Items
Liabilities All credit cards must be turned over to the trustee.
Have you used your credit cards/loans for any purchases or cash advances in the last 3 months? Please select… Yes No
Please provide details.
Has anyone guaranteed any of your debts? Please select… Yes No
Please provide details.
Budget Net Monthly Income Please provide any additional comments or details.
Monthly Non-Discretionary Expenses Total Monthly Non-Discretionary Expenses $
Please provide any additional comments or details
Monthly Discretionary Expenses for Family Unit Housing Expenses Non-Recoverable Medical/Living Expenses Transportation Expenses If you do not own your vehicle and have entered car expenses above, who owns the vehicle?
Personal Expenses Insurance Expenses Other Expenses Total Monthly Discretionary Expenses (Family Unit) $
Total Budget Monthly Surplus (Deficit) $
After completing this form, please upload the following documents: If possible, please upload all documents as one file using the upload tool below.
Proof of Legal Name (Passport, Landed Immigrant Papers, PR Card, Birth Certificate or Citizenship Card) Proof of Spouse’s Legal Name (Passport, Landed Immigrant Papers,PR Card, Birth Certificate or Citizenship Card) I.E. Stub (Social Assistance Stub or Pension – if Direct Deposit, Copy or Current Bank Statement) Spouse’s Current Pay Stub Spouse’s I.E. Stub (Social Assistance Stub or Pension – if Direct Deposit, Copy or Current Bank Statement) Copy of Last Years Income Tax Return & Notice of Assessment Copy of Spouse’s Last Years Income Tax Return & Notice of Assessment (if Self Employed, Need Full Return) Copy of Last Financial Statements for your Business Copy of Spouse’s Last Financial Statements for Their Business Prior Proposal/Bankruptcy Documents Spouse’s Prior Proposal/Bankruptcy Documents Sale of House, Condo, Land etc. in Last 5 Years (Lawyer’s Letter with Closing Documents and Trust Account if Cash Recieved from Sale, Details of How Funds Spent) Sold Assets (RRSP’s/Cars) in Last Year (Sale Documents and Details of How Funds Spent) Garnishment Documents or any other Court Papers Bills/Statements from Creditors and Collection Companies House Appraisal and Mortgage Statement Car Ownership and Security Documents Child/Spousal Support – A Copy of any Agreement Whether You Pay or Recieve Support Upload Tool
