1) GENERAL INFORMATION

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1 1) GENERAL INFORMATION IDENTIFICATION Name : Occupation: Citizenship: Social Insurance number: Medicare number: Date of birth: PROFESSIONAL INFORMATION Employer s name: Date of commencement of employment: Pension fund: yes no Insurance: yes no Previous employers Duration of employment: from to Pension fund: yes no Insurance: yes no Duration of employment: from to Pension fund: yes no Insurance: yes no MEMBERSHIP: ORGANIZATION / PROFESSIONAL ORDER / ASSOCIATION Life insurance: yes no Life insurance: yes no Life insurance: yes no Number: Number: Number: 2 2) ASSETS ACCOUNTS Financial institutions

2 Brokerage Firm INVESTMENTS Investment certificates, bonds, stock, mutual funds, etc. 3 BENEFITS AND DEFERRED INCOME PLANS Pensions and annuities (Québec pension plan, Canada pension plan) File number: File number: Group retirement plans Name of employer: Individual pension plans and other retirement investment plans (RRSP, RRIF, Locked-in RRSP, LRIF, SPP, etc.) Name of institution: Name of person in charge:

3 Name of institution: Name of person in charge: Name of institution: Name of person in charge: 4 LIFE INSURANCE Name of the person insured: Amount: Name of the person insured: Amount: Name of the person insured: Amount: MORTGAGE LIFE INSURANCE

4 Amount: OTHER INSURANCE Disability Hospitalization Medical and dental care 5 Household (fire, theft, liability) Automobile Other (travel, major medical, etc.) Object of the insurance: REAL ESTATE Residence

5 Other real estate (revenue-bearing, secondary residence, vacant land) MOTOR VEHICLES Automobile, van, all-terrain, snowmobile, motorcycle OTHER PERSONAL PROPERTY Boats, furniture, jewelry, collections, leisure and sports articles, etc. LOAN Name of the debtor: Amount of the original loan: $ Balance owing: $ Place where the loan agreement is kept: Reason: 6

6 3) LIABILITIES MORTGAGE LOANS Principal residence Revenue-bearing property, secondary residence OTHER LOANS Personal loans Reason: 7 Reason: Car loan Amount: $ Line of credit Amount: $ Amount: $ Suretyship Name of the person for whom surety has been given: Amount: $ Other debits Payment of support: $ Instalment buying contract: $ Other: $ CREDIT CARDS DEBIT OR BANK CARDS

7 NOTES 8 20/04/2005

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