Debt Solutions Worksheet "*" indicates required fields Step 1 of 9 - Applicant Information 0% EmailThis field is for validation purposes and should be left unchanged.Applicant InformationFull Legal Name* First Middle Last Are you known by any other name?(ex: maiden name)Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Length of Time at this Address:*Primary Phone Number*Secondary Phone NumberEmail Address* Birthday* Month Day Year Social Insurance NumberOccupation*Employer*Employer's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Length of Time with this Employer:*Highest Level of Education:*High School DiplomaDiploma/CertificateBachelor's DegreeMastersPhDHave you ever filed an insolvency before (bankruptcy or proposal)?* Yes No For which did you file? Bankruptcy Proposal How many times have you filed?Have you been discharged? Yes No Marital Status*SingleMarriedDivorcedSeparatedWidowedCommon Law Spouse InformationName of Spouse First Last Birthday Month Day Year Social Insurance NumberOccupationEmployerEmployer's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Length of time with this employer:Highest level of education:High School DiplomaDiploma/CertificateBachlor's DegreeMastersPhDHave you ever filed an insolvency before (bankruptcy or proposal)? Yes No For which did you file? Bankruptcy Proposal How many times have you filed?Have you been discharged? Yes No Date of Bankruptcy: Month Day Year DependantsDo you have any dependants?* Yes No List all dependants:Full NameRelationshipDate of BirthIncome Add Remove Business InformationHave you owned or had an interest in a business in the last five years?* Yes No If yes, what type of business? Corporation Proprietorship Partnership Name of BusinessNature of BusinessLocationWhen commenced: Month Day Year When ceased: Month Day Year Name(s) of Directors/Officers/Partners:Does the business have any assets/receivables? Yes No Please list any assets/receivables?Have all HST returns been filed? Yes No HST #: Transfer of Property/GiftsIf you answer YES to any of the following questions please upload the details at the end of this section. Within the last 12 months have you done any of the following? Please check all that apply.* Sold or transferred any assets (car, investments etc) Made any large or lump sum payments to creditors Had any assets seized by a creditor Received any lump sum payments or settlements No to all of the above For any boxes ticked, implying "YES", please provide details:Within the last 5 years have you done any of the following? Please check all that apply.* Sold or transferred any real estate (land, house etc) Made any gifts to a relative or other person over $500 Made arrangements to continue to pay a creditor No to all of the above For any boxes ticked, implying "YES", please provide details:Upload supporting documents for transfers of property and/or gifts Drop files here or Select files Accepted file types: pdf, png, jpg, Max. file size: 256 MB, Max. files: 8. Additional QuestionsAre you involved in civil litigation from which you may receive monies or property?* Yes No Please provide details:Has anyone left you an inheritance, which you have not yet received or are you expecting to receive any sums of money, which are not related to your normal income or any other property within the next 12 months?* Yes No Please provide details:Are there any writs, judgments, or garnishments outstanding against you?* Yes No Please provide details:Do you bank with a financial institution to which you owe money (including overdrafts, credit cards, lines of credit), or do you have any automatic debits or post dated cheques for debt payments?* Yes No Please provide details:Have you obtained new credit in the last three months or made any purchases on credit in the last three months?* Yes No Please provide details:Are you currently involved in a matrimonial dispute with respect to property?* Yes No Please provide details:Are you storing any personal property which does not belong to you?* Yes No Please list the personal property that you are storing:Have you any debts arising from the following? Please check all that apply.* Fines or penalties imposed by the court Recognizance or bail bond Fraud, embezzlement, obtaining property by false pretenses Employment insurance overpayments None of the above Please provide details:For which year was your last tax return filed?*(ex: 2024)What was the outcome of your last tax return?* Refund received Amount owing Refund to come Have never filed a tax return List all Employers for the past year:Name/Address of EmployerStart DateFinish Date Add RemoveCause of Insolvency:*Describe what, in your own opinion, is the cause of your current financial problems. Monthly Net Family IncomeEmployment Income:ApplicantEmployment Income:SpousePension Income:ApplicantPension Income:SpouseChild Support:ApplicantChild Support:SpouseChild Tax Benefit:ApplicantChild Tax Benefit:SpouseE.I. Benefits:ApplicantE.I. Benefits:SpouseSocial Assistance:ApplicantSocial Assistance:SpouseSelf-Employment Income:ApplicantSelf-Employment Income:SpouseOther Net Income:ApplicantOther Net Income:SpouseTotal Income:ApplicantTotal Income:SpouseTotal Combined Income:Please provide details about the other net income received:Monthly Non-Discretionary ExpensesChild Support Payments:ApplicantChild Support Payments:SpouseSpousal Support Payments:ApplicantSpousal Support Payments:SpouseChild Care:SpouseChild Care:ApplicantFines/Penalties imposed by the Court:ApplicantFines/Penalties imposed by the Court:SpouseEmployment Expenses:ApplicantEmployment Expenses:SpouseMedical/Dental:ApplicantMedical/Dental:SpouseMonthly Living ExpensesFood/Groceries:Rent/Mortgage:Laundry/Dry-cleaning:Heating Costs:Clothing:Electricity:Internet:Telephone:Cable:Cell Phone:Property Tax:Smoking:Alcohol:Entertainment/sports:Other:Gifts/Charity donations:Monthly Transportation CostsCar Lease/Loan Payments:Gas/Repairs/Maintenance:Public Transportation:Monthly Insurance CostsVehicle:Home/Property:Other: AssetsCash on Hand/in Bank:Description/LocationEstimate ValueSecured? (yes/no) Add RemoveStocks, Bonds, GIC's:Description/LocationEstimate ValueSecured? (yes/no) Add RemoveRESP's, RRSP's:Description/LocationEstimate ValueSecured? (yes/no) Add RemoveInsurances w/ Cash Surrender Value:Description/LocationEstimate ValueSecured? (yes/no) Add RemoveFurniture/Personal Effects:Description/LocationEstimate ValueSecured? (yes/no) Add RemoveReal Estate:Description/LocationEstimate ValueSecured? (yes/no) Add RemoveInclude house, land, cabin/cottage as separate line itemsMotorized Vehicles:YearMakeModel Add RemoveIncludes cars, trucks/vans, motorcycle, ATV, snowmobile, trailer, and/or mobile home as separate line itemsTools of the Trade:Description/LocationEstimate ValueSecured? (yes/no) Add RemoveOther Assets of Value:Description/LocationEstimate ValueSecured? (yes/no) Add RemoveAdditional AssetsFarming Assets:Description/LocationEstimate ValueSecured? (yes/no) Add RemoveBusiness Assets:Description/LocationEstimate ValueSecured? (yes/no) Add RemoveCreditorsList all debts including all mortgages, vehicles, leases and family debts as separate line items. DebtsCreditor Name/AddressAccount #Account $Secured? (yes/no) Add RemoveIs there anyone co-signed on any of the above mentioned debts?* Yes No Please indicate which debts have co-signers?Have you guaranteed or co-signed the debts of any other individuals or companies?* Yes No If yes, please provide details: DeclarationI hereby certify that the information contained in this application is true, correct and complete in every respect and fully discloses the state of my affairs.* I AgreeDate:*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature:* First Last
