Evaluation Form

Frank J. Jaglowitz, C.A., Trustee in Bankruptcy
73 Water Street North, Suite 600
Cambridge, Ontario N1R 7L6 (Main Office)
519-623-3820 519-622-3144 (Fax)

Bracebridge, Gravenhurst, & area
705-645-2660 866-261-1119(Toll-Free Fax)

INFORMATION FORM

To help us assess your personal financial situation, you
are asked to carefully complete the following questionnaire.
Should you decide to proceed with bankruptcy,
the answers given will assist us in the preparation of the documents required.

PERSONAL DATA

Name:_______________ _____________ ______________________
     (First)          Middle)       (Last)

Are you known by any other name? If yes,___________________________________

Social Insurance No.: ___________
Birthdate: Year ____ Month ___ Day ___
Telephone: (Home) ________________ (Work) ________________

Address:_______________________________________________

        ______________  ______________  ____________
        (City)           (Province)     Postal Code)

You have resided at this address since:
Year _____ Month ___ Day ___
Contact Address (family member or friend):_______________________
Email address: ________________________________

EMPLOYMENT INFORMATION

Employed: ______ Not Employed: ______ Self-employed: ______

Occupation: __________________________________

Name of Employer:_____________________________
Telephone No: _____________

Address of Employer:_______________________________________________

Employed/Unemployed since: Year ______ Month _____ Day ____

Other Employers this Year:_________________________________________________

Address: __________________________________________________________

SPOUSAL INFORMATION

Marital Status: Married __  Widowed   __  Divorced __
                Single __  Common-law__  Separated _

Has your martial status changed in the last year?
Yes __ No __
How and When?____________________________________________

Spouse's Name:___________ _____________ _________________
(First) (Middle) (Last)
Spouse's Address (if different from applicant):
__________________________________________________________
Spouse's Telephone:(Home) ____________
(Work) ____________
Spouse's S.I.N.:_________
Spouse's Birthdate: Year____ Month___ Day___
Spouse's Occupation:____________________
Since: Year____ Month___ Day___
Spouse's Employer's Name: _______________________
Phone No.____________
Spouse's Employer's Address:__________________________________________

DEPENDENTS LIVING WITH YOU

Full Name	Relationship	Date of Birth	Yearly Income

BUSINESS INFORMATION

Have you owned or had an interest in a business in the last 5 years?
Yes ___ No ___ If yes, give details: _____________________________________

Were any of your debts incurred in the conduct of a business?
Yes ___ No ___

Have you co-signed or guaranteed a debt for anyone?
Yes ___ No ___ If yes, please indicate: __________________________________

Type of debts co-signed or guaranteed: Business____ Personal____ Both ___

Lender's Name and Address	Amount of Loan	Borrower's Name and Address	Is Party Bankrupt?	Business or Personal	Type of Business

FINANCIAL INFORMATION

1. Within the last 12 months, have you.... Details

Sold, disposed of or transferred any of your assets or de-registered any RRSPs? ___ Yes ___ No
Made payments in excess of regular payments to a creditor? ___ Yes ___ No
Had assets seized by any creditor? ___ Yes ___ No
Given security to any creditor? ___ Yes ___ No

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

Sold, disposed of or transferred any real estate?
___ Yes ___ No

Made gifts to relatives or others in excess of $500?
___ Yes ___ No

3. Within the last 3 months, have you .... Details

Returned goods to creditors that you bought on credit
___ Yes ____ No

Borrowed money or purchased
anything on credit.

___ Yes ____ No

4. Are you making alimony and/or maintenance payments?
Yes _ No _
To whom: ________________________________
S.I.N.___________________
    Do you have an agreement or Court Order? Yes _ No _
     (If yes, please bring it with you.)
What is your monthly payment? ___________
Are you in arrears?_______

5. Have you debts arising from:
Fine/penalty imposed by Court? Yes___ No___
Fraud?     Yes ___ No _
Student Loan? Yes___ No___
Embezzlement? Yes __ No __
Misappropriation? Yes___ No___
Assault? Yes ___ No ___
Obtaining property by false pretence or fraudulent misrepresentation?
   Yes___ No___ If yes, give details: ____________________________________

6. Are you suing anyone from whom you may receive monies or property?
   Yes___ No___ If yes, give details:____________________________________

7. Have you received an inheritance in the last year or
is there an ongoing estate?
   Yes___ No___ If yes, give details:_____________________________________

8. Have you given a creditor permission to take deductions
from your pay cheque?
   Yes___ No___ If yes, give details: ____________________________________

9. Has any creditor commenced Court action against you?
   Yes___ No___ If yes, give details: ____________________________________

10. When did you first realize you were having financial difficulties?

    __________________________________________________________

11. What do you feel are the causes of your financial difficulties?

1. __________________________________________________________

2. __________________________________________________________

3. __________________________________________________________

INCOME AND EXPENSES

MONTHLY INCOME                  Bankrupt     Other members
                                             of family unit

Employment Income              _________
Pension/Annuities              _________
Child Support                  _________
Spousal Support                _________
Employment Insurance Benefits _________
Social Assistance              _________
Self-Employment Income         _________
   Gross ________               _________
Other Income                   _________
(details _____________)

TOTAL MONTHLY INCOME           $_________ $_________

TOTAL MONTHLY INCOME OF FAMILY UNIT         $_________

MONTHLY NON-DISCRETIONARY EXPENSES

Child Support Payments         _________
Spousal Support Payments       _________
Child Care                     _________
Medical Condition Expenses     _________
Fines/Penalties                _________
Employment-Related Expenses    _________
Debts where Stay has been lifted _________
Other Expenses                 _________
(Provide details _____________)

TOTAL MONTHLY NON-
DISCRETIONARY EXPENSES         $_________ $_________

TOTAL MONTHLY NON-DISCRETIONARY
EXPENSE OF FAMILY UNIT                     $_________

MONTHLY DISCRETIONARY EXPENSES (Family Unit)

Housing Expenses
Rent/Mortgage                    _________
Property Taxes/Condo Fees        _________
Heating/Gas/Oil                  _________
Telephone                        _________
Cable                            _________
Hydro                            _________
Water                            _________
Furniture                        _________
Other                            _________

Living Expenses
Food/Grocery                     _________
Laundry/Dry Cleaning             _________
Grooming/Toiletries              _________
Clothing                         _________
Other                            _________

Transportation Expenses
Car Lease/Payments               _________
Repair/Maintenance/Gas           _________
Public Transportation            _________
Other                            _________

Insurance Expenses
Vehicle                          _________
House                            _________
Furniture/Contents               _________
Life Insurance                   _________
Other                            _________

Personal Expenses
Smoking                          _________
Alcohol                          _________
Dining/Lunches/Restaurants       _________
Entertainment/Sports             _________
Gifts/Charitable Donations       _________
Allowances                       _________
Other                            _________

Non-Recoverable Medical Expenses
Prescriptions                    _________
Dental                           _________
Other                            _________

Payments
To the Estate                    _________
To Secured Creditor              _________
(Other than mortgage and vehicle)_________
Other                            _________

TOTAL MONTHLY DISCRETIONARY EXPENSES (FAMILY UNIT) $_________

BANK INFORMATION

Do you have any credit cards?
Yes ___ No ___ If yes, give details: _____________________________________

Do you have a safety deposit box?
Yes ___ No ___ If yes, give details: _____________________________________

Are you maintaining any bank accounts at present?
Yes ___ No ___

Bank Name and Address	Account Number

TAX RETURNS

What was the last tax return filed? Year __________
(Bring copy of this tax return.)
     Taxes paid: __________________
     Taxes owing: __________________
     Refund received: __________________
     Refund expected: __________________

INCOME HISTORY

List all sources of income from January 1 of last year to the date of this application.

Source (ie. List employer’s name, or whether UIC, Social Assistance, no income, etc.)	Employer’s Name and Address	Started	Ended

ASSETS

LOCATION	Estimated Value in $
Property: House Cottage Land
Motorized and Recreational Vehicles (including cars, trucks, boats, campers, trailers, snow machines, etc.) Make Year Mileage Serial Number
Household furnishings and appliances
Personal effects and jewellery
Cash surrender value of insurance policies Name of Insurance Company ___________________________________ Account number ___________________________________
Retirement savings plans (R.R.S.P.) Name of bank/insurance company ___________________________________ Account number ___________________________________
Registered Education Savings Plan (R.E.S.P.)
Stocks and shares (including your own company and cooperatives)
Canada Savings bonds (including payroll deduction)

Does anyone owe you money?

Personal property used to earn income (tools of trade) - describe:
Other:
TOTAL ASSETS:

Location of above assets: _______________________________________________
Jointly owned with spouse? Yes ____ No ____

DEBTS
J - Joint
H - Husband
W - Wife

MORTGAGES and OTHER SECURED LOANS		SECURITY	ACCOUNT NUMBER	AMOUNT
J H *W	1. _________________________________ Name ____________________________________ Address ____________________________________ City Postal Code	Vehicle __ Furniture ___ House ___ Cosigner__
J H *W	2. _________________________________ Name ____________________________________ Address ____________________________________ City Postal Code	Vehicle __ Furniture ___ House ___ Cosigner _
J H *W	3. _________________________________ Name ____________________________________ Address ____________________________________ City Postal Code	Vehicle __ Furniture ___ House ___ Cosigner _

CREDIT CARDS AND OTHER DEBTS		ACCOUNT NUMBER	AMOUNT
Bank overdrafts, income tax debts, friends/family, utilities, maintenance or alimony, student loans, Health Care, NSF cheques, etc.
J H W	1. _______________________________________________ Name _______________________________________________ Address _______________________________________________ City Postal Code
J H W	2. _______________________________________________ Name _______________________________________________ Address _______________________________________________ City Postal Code
J H W	3. _______________________________________________ Name _______________________________________________ Address _______________________________________________ City Postal Code
J H W	4. _______________________________________________ Name _______________________________________________ Address _______________________________________________ City Postal Code
J H W	5. _______________________________________________ Name _______________________________________________ Address _______________________________________________ City Postal Code
J H W	6. _______________________________________________ Name _______________________________________________ Address _______________________________________________ City Postal Code

Have you been bankrupt before? Yes ___ No ___

If yes, under what name did you file? ___________________________________

Have you filed a proposal before? Yes ______ No ______

If yes, under what name did you file? ___________________________________

Name of Trustee: __________________________________

Place Assignment Filed: _________________________

Date of Bankruptcy: Year_____ Month____ Day____

Date of Discharge: Year_____ Month____ Day____

INFORMATION REQUIRED FOR BANKRUPTCY INTERVIEW
Birth Certificate
Social Insurance Number
Listing of Creditors with Accounts Numbers OR
Most Recent Statements from Creditors
Most Recent Pay Stub
Credit Cards
Updated Bank Books
IF BANKRUPTCY IS BUSINESS RELATED, PLEASE BRING ABOVE PLUS
Financial Statements
Inventory Listing
Last Prepared Tax Return

How did you find Collins Barrow?		Why did you choose Collins Barrow?
Yellow Pages: Bankruptcy		Location of Office
Catholic Family Counselling		Response from Staff
Office of the Superintendent of Bankruptcy		Recommendation of Lawyer
Lawyer		Recommendation of Friend
Friend		Someone I know used Frank J. Jaglowitz as their Trustee
Internet		I like the Ad
Other		Other

Sold, disposed of or transferred any real estate? ___ Yes ___ No
Made gifts to relatives or others in excess of $500? ___ Yes ___ No

Returned goods to creditors that you bought on credit ___ Yes ____ No
Borrowed money or purchased anything on credit. ___ Yes ____ No