Initial Application

This confidential application form can be completed and submitted independently or if you prefer a member of our staff would be happy to review your financial situation and can complete with you. Should you wish to complete independently please provide answers to the best of your knowledge. If there are fields that you are unsure on how to complete, the trustee will discuss with you upon review.



    Personal Data

    Last Name:

    First Name:

    Middle Names:

    Previous Legal Names / AKA:

    Street Address:

    City and Province:

    Postal Code:

    I have resided at the above address since:

    S.I.N:

    Birthdate: (Y/M/D):

    Email:

    Telephone: (Home):

    Telephone: (Cell):

    Telephone: (Bus.):

    Relationship Status:

    Gender:

    Mailing Address (if different):

    Have you ever been Bankrupt, either in Canada or elsewhere?

    Have you ever filed a proposal under the Bankruptcy and Insolvency Act?

    If you have previously filed a previous Bankruptcy or Proposal, please describe the causes of your financial difficulties?



    Family Information

    Full name and address of spouse or common-law partner (if applicable):

    Occupation and place of employment of spouse:

    Birthdate of spouse:

    Spouse's S.I.N.:

    Number of dependents who rely on you for financial support:

    Full Name Relationship Birthdate Address (if different)



    Employment Information

    Current Employment Status:

    Name of Current Employer:

    Present Occupation:

    How long have you been employed by present employer (if applicable):

    Address of Present Employer:

    Have you been self-employed or owned / operated a Business in the last five (5) years?

    Business Name Nature of Business Incorporated or Sole Proprietorship Max Number of Employees Business Number Start and End of Operations Dates

    In the last 5 years have you been the director of any companies?

    Do any of the businesses have outstanding tax liabilities?

    Do any of the Businesses have Assets?

    Have you personally co-signed for any business debts?



    Household Budget

    Monthly Income

    Net Employment Income:

    Net Earnings of Spouse:

    Net Pensions/Annuities:

    Net Child Support:

    Other net income:

    Canada Child Benefit:

    Net Spousal Support:

    Net Employment Insurance Benefits:

    Net Social Assistance:

    Self-Employed Gross:

    Self-Employed Net:

    Total Monthly Income:



    Monthly Non-Discretionary Expenses

    Child Support Payments:

    Spousal Support Payments:

    Child Care:

    Medical Condition Expenses:

    Fines/Penalties Imposed by Court:

    Expenses as a Condition of Employment:

    Debts Where Stay Has Been Lifted:

    Other:



    Monthly Discretionary Expenses

    Housing Expenses

    Rent/Mortgage:

    Property taxes/condo fees:

    Heating/gas/oil:

    Telephone/cell phone:

    Cable/Internet:

    Hydro:

    Other housing expenses:

    Personal Expenses

    Smoking:

    Alcohol:

    Dining/lunches/restaurants:

    Entertainment/sports:

    Gifts/charitable donations:

    Bank fees:

    Other personal expenses:

    Living Expenses

    Food/grocery:

    Laundry/dry cleaning:

    Grooming/toiletries:

    Clothing:

    Transportation Expenses

    Car lease/payments:

    Repairs/maintenance/gas:

    Public transportation:

    Insurance Expenses

    Vehicle:

    House / Contents:

    Life Insurance:

    Non-recoverable Medical Expense

    Prescriptions:

    Dental:

    Payments

    To secured creditor (Other than mortgage and vehicle)

    Other:



    Total Monthly Discretionary Expenses

    Assets

    Type of Asset Description Estimated Present Value
    Garage Sale Pricing
    Is Asset Secured
    Cash on hand (or in the bank) over $2,300
    Furniture
    Clothing and Personal Effect
    Registered Products (e.g. RRSP,TSFA, RESP, Life Insurance, Pensions)
    Non-Registered Products (eg. GIC, Stocks, Bonds)
    Property
    Automobiles
    Recreational Equipment (eg. Trailers, Boats, RV’s)
    Estimated Tax Refund
    Tools of Trade
    Other Assets of Value



    Debts

    Please list all creditors including any secured creditors. Common creditors may include overdraft with your current financial institution, CRA, mortgages, car loans etc. If the debt is solely in your name or if the debt is joint with another party please indicate in the following manner:

    • If the debt is Joint with another party please provide a "J" in the Ownership box.
    • If you and a spouse and are filling this application jointly please provide a "P" for the Primary applicant a "S" for the Spouse or a "J" if the debt is Joint between the two of you in the Ownership box.
    Creditors Name Ownership (J / A / S) Account Number Amount

    Have you guaranteed or co-signed for any debts for someone else?

    If yes, please provide details:



    Additional Information/Comments

    1. During the last 12 months have you sold, disposed of, or transferred any of your assets (include RRSP’s, household goods, properties, and vehicles)? If yes, please describe.
    2. During the last 12 months have you made payments to any of your creditors in excess of the regular payment? If yes, please describe.
    3. During the last 12 months have you had any property seized? If yes, please describe.
    4. During the last 5 years have you sold, disposed of, or transferred any of your assets? This would include RRSP’s. If yes, please describe.
    5. During the last 5 years have you given any gifts to relatives or others in excess of $500? If yes, please describe.
    6. Do you expect to receive any sums of money which are not related to your normal income, or any other property within the next 12 months? Would include inheritance, life beneficiary settlement, proceeds from civil litigation ect. If yes, please describe.
    7. Has anyone started legal proceedings against you? If yes, please describe.
    8. Does anyone owe you money? If yes, please describe.
    9. How would you describe the cause of your financial difficulties? Please describe below.
    10. Do you owe money to the financial institution you are currently banking with?
    11. When did you last file your taxes?
    12. Who would be an emergency contact for yourself? Please provide name and phone number.
    13. How did you hear about Douglas Loiselle and Associates Inc.?

    After submitting your application, the trustee will review and get back to you within 2 business days to discuss your options.