***THIS FORM MUST BE COMPLETED IN FULL***

Transcription

1 BANKRUPTCY/PROPOSAL APPLICATION CHECKLIST 1. Application - complete all questions - bring 2 pieces of identification when you sign up (i.e. driver s licence & birth certificate) 2. Vehicles - copy of vehicle registration(s) - independent appraisals (two required, usually from vehicle car lots) 3. Real Estate - market evaluations (2) (appraisal or valuation) - copy of mortgage payout statement(s) - copy of insurance on real estate 4. Agreements - debentures, mortgages, separation, alimony, child support, leases, sales contracts, judgments, fines, wage assignments, court orders 5. Credit Cards - all must be turned over to the Trustee, including those with a nil balance 6. Life Insurance - copy of all policies 7. RRSP s/resp s/bonds/securities - all pertinent documentation/statements 8. Income Information - most current pay stub available showing year to date amounts, deductions, etc. 9. Creditor Statements - most recent statements from creditors & collection agencies 10. Student Loans - you may wish to verify your student loan status by calling Tax Information - copy of last return filed - if you have not filed up to date, please provide information for Trustee to file previous year (T4 s, receipts, etc.) - re: current year a list of all employers with gross earnings and deductions made for tax, CPP, EIC, union dues and any maintenance/support payments and spousal earnings 12. Initial filing fee to Bankruptcy Estate $ (by cash or money order only) ***THIS FORM MUST BE COMPLETED IN FULL*** Page 1 of 13

2 HAYES MCNEILL & PARTNERS LTD. TRUSTEE IN BANKRUPTCY CONFIDENTIAL DETAILED APPLICATION Please answer to the best of your knowledge. When you have completed the application please deliver it to our office. We will contact you to make arrangements for a meeting to sign the prepared legal documents. PERSONAL INFORMATION (Full Legal Name Required) Last Name: First Name: Middle Name(s): Address: Street City Province Postal Code Mailing address (if different from above) Resided at above address since: Year Month Day Phone #: Home Cell Business address S.I.N. Birth date: Year Month Day Highest Level of Education: Some High School High School Some Post-Secondary Post Secondary University Degree Occupation: Marital Status: Single Common Law Married Separated as of Divorced as of Widowed as of Spouse s Full Name: Spouse s Phone # Address: Street City Province Postal Code Spouse s S.I.N. Spouse s Birth date Year Month Day Spouse s Occupation Nearest Relative: Name, Address and Phone Number Relation Number of Dependents who rely on you for financial support: (list below) Name Income Since January 1 Relationship Birth date Live with Bankrupt? Page 2 of 13

3 DEBTS: List all debts, including secured debts and utilities (best estimate of balance owing) Creditors Name Complete Address Account Number Estimated Amount Owing When listing all your debts please indicate if another person is also legally responsible to pay the debt. Please separate debts if filing joint with your spouse. Page 3 of 13

4 ASSETS DESCRIPTION BEST ESTIMATE OF PRESENT VALUE Cash on hand/in Bank Household Furniture/Effects Accounts Receivable (due to you) (provide list showing names/address/ amount) Cash Surrender Value of Insurance Policies Pensions (Company, Plan #) (to calculate see last two pages of application) RRSP (Company, Plan #) RESP (Registered Education Savings Plan) Stocks/Credit Union Shares Shares in Limited Company (Give # of shares, company name Cottage / Timeshare (give address & legal description) House (give address & legal description) Land (give address & legal description) Automobile (give year/model/vin #) Motorcycle (give year/model/vin #) Other Vehicles Boat (model & size) Motor (type & size) Trailer Recreational Equipment Other Assets (e.g. inheritances/litigation/etc.) Please supply copies of all relevant documentation including copies of car registration/appraisals/mortgage documents/insurance policies/share certificates etc. Page 4 of 13

5 Have you been self employed in the last 5 years? Yes No BUSINESS AND TRADE NAMES Business #1 Business #2 Sole Proprietorship, Partnership or a Corporation. Start Date / End Date (yr/mth/day) What Happened to Business? Where are Books & Records? Are they up to date? Name(s) of Partner(s) Place of Business (City) Nature of Business GST # Are there any outstanding GST returns? For what periods? Are the employees paid? Are the T4 s completed? How many employees? Are any of your debts directly related to your business? Yes If yes, what percentage? % Are you an Officer or a Director of a limited company? Yes (If so you may need to resign as director) No No If yes - Name of the Company - Date you became a Director or Officer - Is the company still operating? Yes No - Where are the books and records? List all of your employers, showing dates started and terminated, for the past two years. If you had any periods when you were drawing EI benefits, show each period separately. Employer`s Name Employer`s Full Address Date Job Commenced Date Job Finished EI Benefit Terminated Page 5 of 13

6 REASONS FOR YOUR FINANCIAL PROBLEMS: Over-extension of credit Relationship Breakdown Medical Issues Business failure Alcohol/Drugs/Gambling Poor Financial Management Provide short description PREVIOUS BANKRUPTCY, ETC: Have you ever been bankrupt before? If yes: Name bankruptcy was filed under Date of Bankruptcy Name of Trustee/Prov. Provide reasons for previous bankruptcy Please supply a copy of Discharge Order. Have you ever made a proposal or an arrangement with your creditors? If yes, please detail GENERAL: 1. Within the last twelve (12) months, have you sold, disposed of, or transferred any of your assets? Yes No (e.g. Vehicles, RRSP s, Stocks/Bonds, Furniture) - If yes, provide details below. Description of Asset Date Disposed To Whom ie: Spouse/Relative/Other Sale Price Where are the sale proceeds? 2. Within the last twelve (12) months, have you made payments in excess of regular payments to any creditor, or paid any one creditor s debt in full? Yes No If yes, detail; 3. Within the last twelve (12) months, have you had any assets seized, garnished or repossessed by a creditor? (ie: paycheque, bank acct, vehicles, refunds) Yes No Asset Seized: Date Seized: Value: Name of party that seized: Was party who made seizure a secured creditor? Yes No Form of security? (Please provide copy of seizure/garnishee document) Page 6 of 13

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8 4. Within the last five (5) years, have you sold, disposed of, or transferred any real estate? Yes No Description and address of Property Date Disposed To Whom Sale Price Where are the sale proceeds? 5. Within the last five (5) years, have you made any gifts to relatives or other in excess of $500? Yes No If Yes, detail: 6. Have you made any arrangements to continue to pay any creditors in the future? Yes No If yes, detail: 7. Do you expect to receive any sums of money, or any other property within the next 12 months, which are not related to your normal income? Yes No If yes, detail: 8. Does anyone owe you any money? Yes No If yes, detail: 9. Are you related in any way to an individual that has used, or is using, the services of Hayes McNeill & Partners Ltd.? Name Relationship Bankrupt or proposal 10. Do you currently own any of the following? (a) Collectibles (stamps, coin, art, antiques, etc) Yes No $ (b) Savings Bonds (owned presently or being purchased) Yes No $ (c) RRSP s, GIC s, LIRA s Yes No $ (d) Shares (owned presently or being purchased) Yes No $ Please provide details : (e) Personal Life Insurance Policies (include a copy) Yes No $ Please provide details : 11. Are you a beneficiary of a will or will you receive an inheritance? Yes No $ Please provide details : 12. Has anyone started legal proceedings against you? Yes No $ Page 8 of 13

9 Please provide details 13. Do any of your debts arise from: A fine or penalty imposed by court Yes No $ Alimony or maintenance payments Yes No $ Fraud, embezzlement, misappropriation Yes No $ Student Loans Yes No $ 14. For which year did you file your last income tax return? Did you receive a refund? Yes No $ Where are the proceeds? 15. Are you paying/receiving any alimony or maintenance? Yes No If yes, to/from whom Amount since January 1 st $ (Please provide a copy of the Court Order or separation agreement) Have you co-signed or guaranteed any loans? Amount of loan $ Borrower s Name & Address: Lender s Name & Address: Business or Personal Debt? Is party bankrupt? INCOME SUMMARY (MONTHLY) PER MONTH Net Salary (after deductions) $ Net Self Employment Earnings (after business expenses) Pension/Annuities CPP $ OAS $ Other $ Total Other Pension Income (disability, union, etc.) Net Earnings of Spouse (if living with you) Alimony Received EI (Employment Insurance Benefits) Child Tax Benefit / UCCB Social Assistance Rental Income Other (specify) TOTAL MONTHLY INCOME $ Page 9 of 13

10 EXPENSE SUMMARY Child support payments you pay $ Spousal support payments Child care (daycare) Expenses associated with a medical condition (not including MSP premiums) Fines/penalties being paid Employment-related expenses (If not reimbursed by employer) Debts where stay has been lifted Rent Mortgage Room & Board (Tick one) Property taxes Heating Telephone / Cellular Telephone Cable / Internet Hydro Smoking Alcohol Miscellaneous - Dining Out - Sports/Entertainment - Other Food/Groceries Laundry Hygiene Products Clothing Car or Truck Payments Transportation costs (fuel/repairs & maintenance) Car insurance Insurance on house/contents Life insurance Payment being made to Trustee Loan payments (to secured creditors) Details TOTAL MONTHLY EXPENSES $ PER MONTH Comments regarding above income and expenses: Page 10 of 13

11 Hayes McNeill & Partners Ltd. ( HMPLTD ) Consent Under the Personal Information Protection Act ( PIPA ) of British Columbia I, the undersigned person, hereby consent to HMPLTD collecting, using, and disclosing any personal information that I or any other party may give to HMPLTD about me for the purpose of providing advice to me and/or in the performance of HMPLTD s duties whether it is assisting me in settlements with creditors or in the performance of HMPLTD s duties as Trustee under a Proposal or as Trustee in Bankruptcy under the Bankruptcy and Insolvency Act. For example, I consent to the collection, use, and disclosure of personal information which may be of a financial nature such as my personal assets and debts, personal income and expenses, and any information related to my income tax returns and related information, and any other personal information that I or others may provide to HMPLTD for the purpose of performing of its duties under the Bankruptcy and Insolvency Act and as consultant where any engagement is not under the Bankruptcy and Insolvency Act. For example, I acknowledge that the disclosure of such personal information, which I or others provide, may be provided to my creditors, Canada Revenue Agency, Superintendent of Bankruptcy, the Official Receiver, other interested parties, and the Court, for the purpose of fulfilling any engagement and your legal and professional obligations and I consent to such disclosure. I have been given a chance to ask any questions I have about the Privacy Policies and they have been answered to my satisfaction. I agree to HMPLTD collecting, using and disclosing personal information about me as set out above and in the HSLCO s Privacy Policy. Dated at, BC, this day of, 20. Signature: Name: Page 11 of 13

12 INVENTORY OF ASSETS HOUSEHOLD FURNISHINGS & APPLIANCES EXEMPT (Best Estimate of Liquidation Value) LIVING ROOM KITCHEN STUDY Sofa $ Table $ Desk $ Chairs(s) Chairs Chair(s) Lamps Pots/Pans Computer Stereo Equip Dishes CD Player Microwave DINING ROOM DVD Player Freezer Table $ TV Washer/Dryer Chairs VCR Fridge Cabinet Stove China/Silver BEDROOM #1 BEDROOM #2 BEDROOM #3 Bed $ Bed $ Bed $ Dresser Dresser Dresser Night Stand Night Stand Night Stand CLOTHES $ TOTAL EXEMPT $ NON-EXEMPT - (you may be required to pay for these or sell them) JEWELLERY OTHER COLLECTIONS Rings $ Bike(s) $ Coin Watches Ski Equipment Stamp Necklaces Camping Equip Plate Sporting/Outdoors Gun TOTAL NON-EXEMPT $ I HEREBY CERTIFY THAT THIS IS A TRUE AND COMPLETE LIST OF ALL MY HOUSEHOLD AND PERSONAL EFFECTS AND THAT THE ASSIGNED VALUES ARE THE TRUEST VALUES TO THE BEST OF MY BELIEF. Date: Signature: Page 12 of 13

13 UNINCORPORATED TRADE AND BUSINESS ASSETS Exempt Assets Tools and Equipment (attach list) Description Location Value TOTAL Other Non - Exempt Assets Inventory (attach list) Accounts Receivable (attach list) $ $ I HEREBY CERTIFY THAT THIS IS A TRUE AND COMPLETE LIST OF ALL MY TRADE AND BUSINESS ASSETS AND THAT THE ASSIGNED VALUES ARE THE TRUEST VALUES TO THE BEST OF MY BELIEF. Date: Signature: F:\0000MISC\BANKRUPT\Application Form (FINAL) Apr 28, 2105 Page 13 of 13