Individual Affidavit Form printable pdf download

Individual Affidavit Form

In the matter of ____________________________________________________________________

(insert estate number(s) or estate name(s) from the Unclaimed Dividends Database) for unclaimed

dividends held by the Receiver General, I swear or say under penalty of perjury:

1. That I am entitled to the unclaimed dividends specified in the claim attached hereto, as I am

the individual creditor to whom the funds held are payable, or his or her legal representative;

2. That I have knowledge of the circumstances connected with this claim;

3. That I have reason to believe that the Receiver General for Canada holds unclaimed

dividends to which I am entitled in the amount of $ ____________________ (insert amount);

4. That I have not been reimbursed by a third party and the amounts are still owed to me;

5. That I am entitled to request payment of the unclaimed dividends pursuant to subsection

154(1) of the Bankruptcy and Insolvency Act;

6. That I claim the unclaimed dividends pursuant to subsection 154(2) of the Bankruptcy and

Insolvency Act;

7. That I agree and undertake to indemnify Her Majesty and her officers, officials, employees

and agents if it is determined that I was not entitled to the funds;

8. That I live or that I have lived at ________________________________________________

(insert address from Unclaimed Dividends Database); and

9. That the content of the attached Claim Form and supporting documents is accurate and true.

Sworn before me in the city of ___________________________________________ in the province

of ________________________________ this day of __________________________, 20_______.

__________________________________

Commissioner for Oaths

Creditor or legal representative

__________________________________

Print name or stamp

Print name

Individual Affidavit Form