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 and 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):_________________________________


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   Total
                                               of family unit

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

TOTAL MONTHLY INCOME             $_________(1)  $_________(2) 

TOTAL MONTHLY INCOME OF
THE FAMILY UNIT ((1)+(2))                                 $________(3)

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           $_________(4)  $_________(5)

TOTAL MONTHLY NON-DISCRETIONARY
EXPENSE OF FAMILY UNIT ((4)+(5))                          $________(6)

AVAILABLE MONTHLY INCOME
OF BANKRUPT ((1)-(4))            $_________(7)

AVAILABLE MONTHLY INCOME
OF FAMILY UNIT ((3)-(6))                                  $________(8)

BANKRUPT'S PORTION OF AVAILABLE
MONTHLY FAMILY UNIT INCOME
((7)/(8) X 100)                                           % _______(9)


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)       $________(10) 

MONTHLY SURPLUS OR (DEFICIT) FAMILY UNIT ((8)-(10))      $________(11)


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

Check
if exempt

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

 




I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THE APPLICATION FORM IS TRUE, CORRECT AND COMPLETE IN EVERY RESPECT AND FULLY DISCLOSES THE STATE OF MY ASSETS AND LIABILITIES.

*NOTE: THE FACT THAT YOU SIGN THIS FORM DOES NOT MEAN THAT YOU HAVE
COMMITTED YOURSELF TO FILE AN ASSIGNMENT INTO BANKRUPTCY OR A
PROPOSAL.








____________________________________
Signature of Applicant




________________________
Date

 

 


                                                                               RETURN