Debt Relief Worksheet Page 10
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10Debt Relief Worksheet
Page 10
Have you any debts arising from (if you answered yes please attach an explanation and relevant supporting documentation):
Fine or Penalty imposed by the Court (including traffic fines)
Yes
No
Recognizance or Bail Bond
Yes
No
Fraud, Embezzlement, Obtaining property by False Pretenses
Yes
No
Employment Insurance Overpayments
Yes
No
Gambling, Drug or Alcohol Abuse
Yes
No
1
Are your vehicles or other assets insured?
Yes
No
.
2
Has anyone co-signed any of your outstanding debts? If yes, give details below.
Yes
No
.
3
Do you have a safety deposit box?
Yes
No
.
4
Are you currently involved in a matrimonial dispute with respect to assets?
Yes
No
.
5 Are you storing any personal property which does not belong to you? (please list below)
Yes
No
ONLY FOR STUDENT LOANS:
Degree/Certificate Received?
Yes
No
Attended School from
to
Area of Study
Level of Education Completed
Institution Attended
When did you receive funds?
Are you working in that field?
Yes
No
PLEASE UNDERSTAND THAT A STATEMENT OF YOUR FINANCIAL AFFAIRS WILL BE PREPARED FROM THE INFORMATION
SUPPLIED BY YOU ON THIS APPLICATION AND THAT STATEMENT MUST BE SWORN BY YOU UNDER OATH AS BEING, TO
THE BEST OF YOUR KNOWLEDGE AND BELIEF, A FULL, TRUE AND COMPLETE STATEMENT OF YOUR FINANCIAL
AFFAIRS.
I (we), the undersigned person(s), hereby consent to Ira Smith Trustee & Receiver Inc. collecting, using, and disclosing any personal
information (as defined in the Personal Information Protection and Electronic Documents Act) that I (we) or any other party may give to
Ira Smith Trustee & Receiver Inc. about me (us) for the purpose of providing advice to me (us) and/or in the performance of Ira Smith
Trustee & Receiver Inc.’s duties as Trustee under a Proposal or as Trustee in Bankruptcy under the Bankruptcy and Insolvency Act.
I hereby certify that the information contained in this application is true and complete in every respect and fully discloses the state of my
affairs. In addition, I recognize that any income in excess of a reasonable cost of living must be paid to the Trustee for the general
benefit of the creditors.
DATE
SIGNATURE OF APPLICANT
DATE
SIGNATURE OF APPLICANT
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