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PERTINENT INFORMATION RELATING TO YOUR AFFAIRS

I have resided at the above address since:

Marital Status:

List Dependants:

SELF EMPLOYED INFORMATION

Have you been self-employed in the last five-(5) years?

IF yes complete:

Business #1

Business #2

Have you ever owned a corporation?

Have you ever been a Director, Officer or Shareholder of a Corporation?

Within the last 5 years, have you

(a) sold, disposed of or transferred any real estate?

(b) made any gifts in excess of $500 to relatives or to others?

Within the last 12 months, have you

(a) disposed of or transferred any of your assets (i.e. vehicles, furniture, jewellery, stocks, bonds, RRSP’s, GIC’s, etc.)?

(b) made payments to a creditor in excess of regular payments?

(c) had any assets seized by any creditor?

BUDGET INFORMATION

MONTHLY INCOME

MONTHLY EXPENSES

ASSET DISPOSITION

Please provide LOCATION / DESCRIPTION

CREDITOR INFORMATION

Supplementary Information

Employment History – your most recent employer

Income Tax Return Information

Details of Alimony or Child Support payments – indicate the amount paid and to whom:

Have you ever been bankrupt before? Or filed a Proposal?

If yes, give:

You own property or are on title to a property, or guarantor of the mortgage on a property:

If you rent:

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