CO-SIGNER OR GUARANTEES

Have you co-signed or guaranteed a debt for anyone? Yes ____ No ____
If yes, please indicate the type of debts co-signed or guaranteed:
Business ____ Personal ____ Both ____

Lender's Name and Address	Amount of Loan	Borrower's Name and Address	Is Party Bankrupt?	Business or Personal	Type of Business

1. Within the last 12 months, have you

a) Sold, disposed of
or transferred any of your assets/property or de-registered any RRSPs? Yes ____ No ____
If yes, give details: _______________________________________________

b) Made payments in excess of regular payments to a creditor? Yes ___ No ___
If yes, give details: _______________________________________________

c) Had assets/property seized by any creditor? Yes ____ No ____
If yes, give details: _______________________________________________

d) Given security to any creditor? Yes ____ No ____
If yes, give details: _______________________________________________

2. Within the last 5 years, while you knew yourself to be insolvent, have you

a) Sold, disposed of or transferred any property? Yes ___ No ___
If yes, give details: _________________________________________________________________

b) Made gifts to relatives or others in excess of $500? Yes ____ No ____
If yes, give details: _________________________________________________________________

3. Within the last 3 months, have you

a) Returned goods to creditors that you bought on credit

Yes ___ No ____
If yes, give details: ______________________________________________________

b) Borrowed money or purchased
anything on credit? Yes ___ No ____
If yes, give details: ______________________________________________________

Yes ____ No ____

4. 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? Yes _____ No _____
If yes, give details: ______________________________________________________

5. Are you considering making arrangements to continue to pay any creditors while in bankruptcy? Yes ____ No ____
If yes, give details: ______________________________________________________
6. Are you making alimony and/or maintenance payments? Yes ______ No ______
. To whom: _____________________________ S.I.N. __________________________________
. Do you have an agreement or Court Order? Yes ___ No ___ (If yes, please bring it with you.)
. What is your monthly payment? ___________________________ Are you in arrears? __________________
7. Have you debts arising from:
Student Loans? Yes ___ No ___     Assault? Yes ___ No ___
Fine or penalty imposed by Court? Yes __ No__     Fraud? Yes __ No ___
Embezzlement? Yes ___ No ____     Misappropriation? Yes ___ No ___
Obtaining property by false pretence or fraudulent misrepresentation? Yes ___ No ___
If yes, give details: ____________________________________________________
8. Have you given a creditor permission to take deductions from your paycheque? Yes _____ No _____
If yes, give details: ____________________________________________________
9. Has any creditor commenced Court action against you? Yes _____ No _____
If yes, give details: ____________________________________________________
10. Do you have any credit cards other than those previously listed? Yes ____ No ____
If yes, give details: ____________________________________________________
11. Do you have a safety deposit box? Yes ____ No ____
If yes, give details: ____________________________________________________
12. When did you first realize you were having financial difficulties? ________________________________________________________

BUSINESS

Have you owned or had an interest in a business in the last 5 years? Yes ____ No ____
Name of business: ______________________________________________________
Where: ______________________________________________________
Type of business: Corporation ____ Partnership ____ Sole proprietorship ____
Were any of your debts incurred in the conduct of business? Yes ____ No ____

ASSETS
HOUSEHOLD FURNISHINGS AND APPLIANCES: State the number of each item in your possession and indicate the estimated value calculated at auction or garage sale price.

#		Estimated Value in $	#		Estimated Value in $	#		Estimated Value in $
	Stove			Desk			VCR
	Refrigerator			Freezer			Video Camera
	Dishwasher			Washer			Other Cameras
	Microwave			Dryer			Stereo
	Tables/chairs			Lamps			TV
	Lazy-boy			Dining room set			Paintings
	Living room set			Hutch			Silverware
	Carpets			Book case(s)			China/Crystal
	Coffee tables			Patio furniture			Games over $100
	Sewing machine			Lawn mower			Pool table
	Bed(s)			Household tools
	Night tables			Piano Organ
	Dresser(s)			Musical Instruments
Location of above assets: ____________________________________________________________
TOTAL ESTIMATED VALUE $ _______________
OTHER ITEMS
	Golf Clubs			Jewellery
	Bicycles			Sculptures
	Other sporting equip.			Antiques
	Computer			Collections
	Camping equip.
Location of above assets ______________________________________________
TOTAL ESTIMATED VALUE $ _______________
Jointly owned with spouse _____ Yes _____ No

	Location	Exempt	Value
Cash on hand Are you maintaining any bank accounts at present? Yes _____ No _____ If so, specify location, type of account and account number.
Clothing (garage sale or second-hand store value)
Household furnishings and appliances (from page 6)
Does anyone owe you money?
Life insurance policies Name of Insurance Company ___________________________ Policy number ___________________________________
R.R.S.P. Employment Profit Sharing Plan, GIC, Mutual Funds Name of bank/insurance company ________________________ Account number _________________________________
Registered Education Savings Plan (R.E.S.P.)
Calgary Co-op Membership # _______________________
Stocks and shares (including your own company and cooperatives)
Canada Savings Bonds (including payroll deduction)
Estimated tax refund - Year _______
Property: House
Other
How did you determine the value of the property?
Motorized and Recreational Vehicles (including cars, trucks, boats, campers, trailers, snow machines, etc.): Make & Model Year Mileage Serial Number
Personal property used to earn income (tools of trade) Describe
Other:
TOTAL ASSETS

Does your spouse have any assets not listed above? Yes _____ No ______
If yes, give details ________________________________________________________________________

INCOME		FAMILY LIVING EXPENSES: To best of your ability fill in monthly or annual amount for items that apply to you.
List your family's regular monthly income after deductions Net pay		Housing rent or 1st mortgage	Monthly	Annually
		2nd mortgage
Net pay of spouse		property taxes/condo fees
Child tax credit		home insurance
Pensions/Annuities		home maintenance
Child maintenance/alimony		Utilities natural gas, power, water and sewer
EI Benefits
Social Assistance		telephone/long distance/cell phone
Rental income/Boarders		cable T.V.
Other income		Personal Allowances lunches/meals out
TOTAL monthly take-home income (A)		hair cuts
		tobacco
		alcohol
		other
		Recreation - movies, entertainment, fitness classes, sports registrations, etc.
Non-discretionary Expenses Child support		Gifts and festities special holidays, birthdays, etc.
Spousal support		Travel and Vacation vacations, other travel
Child care
Medical condition		Contributions and Donations
Fine/penalties being paid		Education fees, tuition, books, supplies
Debts where stay has been lifted
TOTAL Non-discretionary expenses (B)		Other Monthly Expenses - pets, itmes you plan to buy in the next year
		Medical Expenses (non-recoverable) prescriptions, dental, optical, Alberta Health Care, Blue Cross
		Food (plus other grocery store items)
Employment related expenses (only if deductible for income taxes) Supplies		Household incidentals bank service charges, newspapers, subscriptions, dry cleaning, etc.
		Clothing
Labour		Transportation car lease payments
Transportation
Cell phone		vehicle insurance
Income tax		gasoline
Other		vehicle repair/maintenance
		vehicle license and registration
TOTAL Employment Expenses (C)		parking
		bus fare, passes
Income available after non-discretionary and employment related expenses (A-B-C)		Life Insurance
		Payment to Trustee
Less: Family Living Expenses (D)		Payments to Secured Creditors
Surplus/Deficiency		Divide total annual expenses x 12
		Total Family Living Expenses (D)

TAX RETURNS

Have you filed last year's income tax return? Yes ______ No ______ Year _______ (Bring a copy of this tax return.)

If yes, give details:
Taxes paid/owing: _______________________________________
Refund received/expected: _______________________________________

If no, what was the last year you filed? Year __________ (Bring a copy of this tax return.)

If no, what was the last year you filed? Year __________ (Bring a copy of this tax return.)

INCOME HISTORY

List all sources of income from January 1 of last year to the date of this application.

Source (list employer's name, or whether UIC, Social Assistance, no income, etc.)	Employers' Address	Period
		Started	Ended
YOU
YOUR SPOUSE

What are the causes of your financial difficulties? ____________________________________________

___________________________________________________________________________________

How do you propose paying the fee? _____________________________________________________

How did you find Collins Barrows Limited? Accountant (Acct) _____ Alternatives to Bankruptcy (Alt) _____ Bankrupt (Bkt) _____ Channel 2 (Ch2) _____ Credit Counselling Services of Alberta (CCSA) _____ Office of the Superintendent of Bankruptcy (OSB) _____ Lawyer (L, name) __________ Other (O) __________ TV Guide (TVG) __________ Yellow Pages (YP) __________

Why did you chose Collins Barrow Limited? Location of office (LOC) ______ Response from Staff (S) ______ Recommendation of Lawyer (L) ______ Recommendation of Friend (F) ______ Someone I know used CBL as their Trustee (Bkp) ______ I liked the Ad ______ Other ______

I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THE APPLICATION FORM IS TRUE, CORRECT AND COMPLETE IN EVERY RESPECT AND FULLY DISCLOSES THE STATE OF MY ASSETS AND LIABILITIES.

NOTE: THE FACT THAT YOU SIGN THIS FORM DOES NOT MEAN THAT YOU HAVE COMMITTED YOURSELF TO FILE AN ASSIGNMENT INTO BANKRUPTCY OR A PROPOSAL.

_____________________________________________ Signature of Applicant

______________________________ Date 11/00

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