Debt Relief Worksheet
Interviewed by:
Referred by:
Date Interviewed:
Date Signing:
LAST NAME
FIRST NAME
MIDDLE NAME(S)
ARE YOU KNOWN BY ANY OTHER NAMES? (Incl. Maiden Name)
DATE OF BIRTH (Day/Month/Year)
M / F
SIN
ADDRESS (Include City, Province and Postal Code)
WHEN MOVED THERE (DD/MM/YYYY)
MAILING ADDRESS (if different from above)
PREVIOUS ADDRESS
Level of Education
(if at current address less than
one year)
TELEPHONE NUMBERS
Cell:
Residence:
Business:
EMERGENCY CONTACT (Name & Number)
E-Mail Address
MARITAL STATUS – (Specify: Day/Month/Year)
___ ___ ___
Married
___ ___ ___
___ ___ ___
Widowed
Divorced
___ ___ ___
Single
___ ___ ___
Common-law
___ ___ ___
Separated
OCCUPATION
CURRENT EMPLOYER
SINCE WHEN
ADDRESS OF EMPLOYER
IF UNEMPLOYED, SINCE WHEN
SPOUSE’S ADDRESS (if different than above)
FULL LEGAL NAME OF SPOUSE
M / F
SPOUSE’S SIN
SPOUSE’S BIRTH DATE (yy/mm/dd)
SPOUSE’S EMPLOYER
SINCE WHEN
SPOUSE’S OCCUPATION
IF UNEMPLOYED, SINCE WHEN
SPOUSE’S BUSINESS PHONE:
SPOUSE CELL PHONE:
DEPENDENTS (all those who rely on you for financial support)
FULL NAMES
RELATIONSHIP
DATE OF BIRTH
ADDRESS
INCOME
IF OVER 18, WHY DEPENDENT?