BNA Personal Information Form

Licensed Insolvency Trustee
Personal Information Form

(This form is for information purposes only, completing it does NOT commit you to the process)
Your Administrator with BNA?
Closest BNA Location *
Your Information
Your Name: *

First Name Middle Name Last Name
Also Known As (Alias):

First Name Middle Name Last Name
Current Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Alternate Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
When did you move in?

Month Day Year
Date
Home Phone Number: *

Area Code Phone Number
Cell Phone Number:

Area Code Phone Number
Work Phone Number:

Area Code Phone Number
Ext
Email *
example@example.com
Date of Birth:

Month Day Year
Date
Social Insurance Number
Gender:

Male Female
Highest Education Level:

0-9 Years Some High School High School Graduate Some Post Secondary Post Secondary certificate or diploma University or Higher
Marital Status:

Married Divorced Single Widowed Separated Common Law
Has your marital status changed in the last 5 years?

Yes No
Date of change:

Month Day Year
Date
Changed From:
Emergency Contact Name:
Emergency Contact Phone Number:

Area Code Phone Number
Spousal Information
Will your spouse also be filing a bankruptcy or proposal?

Yes No
Spouses Name:

First Name Middle Name Last Name
Souse Also Known As (Alias):

First Name Middle Name Last Name
Spouse Home Phone Number:

Area Code Phone Number
Spouse Cell Phone Number:

Area Code Phone Number
Spouse Work Phone Number:

Area Code Phone Number
Ext
Spouse Email address:
example@example.com
Spouses Date of Birth:

Month Day Year
Date
Spouse Social Insurance Number:
Spouse Gender:

Male Female
Spouse Education:

0-9 Years Some High School High School Graduate Some Post-secondary Post-secondary certificate or diploma University Degree
Dependent Information
Do you have children?

Yes No

If over 18, why are they still dependent?
Business Information
Have you owned or had any ownership in a business in the last 5 years including a sole proprietorship?

Yes No
Type of Business:

Proprietorship Corporation Partnership
Name of Business:
Nature of Business:
Address of Business (Leave black if home address):

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date Started:

Month Day Year
Date
Date Closed:

Month Day Year
Date
Name of Directors, Officers, Partners:
Does the business have and assets or accounts receivable?

Yes No
Please list:
Have all of the required GST returns been filed?

Yes No
GST Number:
Have the required T4's been prepared?

Yes No
Where are the books and records located?
Employment Information/History
Type a question
Current Employer Name:
Occupation:
Employer Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Start Date:

Month Day Year
Date
If you are unemployed or retired, since when?

Month Day Year
Date
Have you collected EI?
Please provide the start and end date:

List all of your employers for the past year. Include periods when you were drawing EI, WCB or Social Assistance

Employer Name

Address

Start Date

End Date

Employer 1

Employer 2

Spouse’s Employment Information / History
Spouse Type a question
Spouse Current Employer Name:
Spouse Occupation:
Spouse Employer Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Start Date:

Month Day Year
Date
Is your spouse unemployed or retired, since when?

Month Day Year
Date
Has your spouse collected EI?
Please provide the start and end date:

Prior Insolvencies / Other
Have you ever been bankrupt before (either in Canada or elsewhere)?

Yes No
What was the cause of the previous bankrupty?
Date of Bankruptcy:

Month Day Year
Date
Name of Trustee:
Date of Discharge:

Month Day Year
Date
Bankruptcy Location:
Have you filed for a proposal before (either in Canada or elsewhere)?

Yes No
Did you receive your certificate of full performance?

Yes No
How did you hear about us? (Check all that apply):

Accountant BBB BNA Website CCCA Consumer Choice Award Credit Counselling Society Facebook Family and Friend Google Government of Canada Internet LinkedIn Money Mentors Office of the Superintendnt of Bankruptcy Prior Client Realtor Staff Member Telus Top 3 Word of Mouth Yellow Pages Yelp YouTube
Cause of your financial difficulties? (check all that apply):

Overuse of Credit Illness Creditor Garnishee Marital Breakdown Addiction Loss of Income Legal Action Business Failure Tax Debt
Assets

This includes ALL ASSETS IN THE WORLD. Indicate the estimated value using auction or garage sale

Description

Value

Whose Asset

Cash/Chequing/Savings account

Furniture and Appliances

Household Goods: Other

Clothing

Jewelry

Collections

Musical Instruments

Personal Effects: Other

Life Insurance Policies

RRSP

RESP

Tax Free Savings Account

Pensions

Stocks

Bonds

Company or Co-op Shares

Securities: Other

Tools of the Trade

House/Condo/Town home

Mobile Home

Rental Property

Automobile #1

Automobile #2

Automobile #3

Motorcycle

Boat

Snowmobile

Camper/Trailer

Recreational Vehicle: Other

Motor Vehicle Accident Lawsuits

Wrongful Dismissal Lawsuit

Potential Inheritance

Other Assets:

Secured Creditors

Your SECURED debts include mortgages, home equity lines of credits (HELOC), car loans, loans secured to your household goods, etc.

Creditor

Secured to which asset?

Account #

Balance Amount

Whose Debt?

Secured Creditor #1

Secured Creditor #2

Secured Creditor #3

Secured Creditor #4

Secured Creditor #5

Unsecured Creditor

Your UNSECURED debts include credit cards, bank loans, payroll loans, outstanding utilities you do not plan on keeping, tax debt to the CRA, loans to family and friends, overdrafts, lines of credit, student loans etc.

Creditor

Account #

Balance Amount

Whose Debt?

Creditor #1

Creditor #2

Creditor #3

Creditor #4

Creditor #5

Creditor #6

Creditor #7

Creditor #8

Creditor #9

Creditor #10

Creditor #11

Creditor #12

Creditor #13

Creditor #14

Creditor #15

Creditor #16

Creditor #17

Creditor #18

Creditor #19

Creditor #20

Creditor #21

Monthly Income

Please provide the monthly income amounts AFTER taxes.

Self

Spouse

Other Family Member

Net Employment income

Net Pension

Net child support

Net Child Tax Benefit

Net Spousal Support

Net EI benefits

Net Social Assistance

Net Self Employment Income

Other Income

Describe your Other Income
Non-discretionary

Please provide the monthly amount.

Self

Spouse

Other Family Member

Child Support Payments

Spousal Support Payments

Child Care

Medical Condition expenses

Fine and penalties imposed by court

Expenses as a condition of employment

Debts where stay has been lifted

Other expenses

Describe your Other Non-discretionary Expenses
Monthly Discretionary Expenses (Family Unit)

Please provide the monthly amount

Amount

Description

Rent/Mortgage

Property Taxes/Condo Fees

Heating/Gas/Oil

Telephone/Cell phone

Cable/Internet

Hydro

Water

Other Housing Expense

Smoking

Alcohol

Dining/Lunches/Restaurants

Entertainment/Sports

Gifts/Charitable Donations

Allowances

Other Personal Expenses

Dental

Other Medical Expenses

Food/Groceries

Laundry/Dry Cleaning

Grooming/Toiletries

Clothing

Other Living Expenses

Car Payments/Lease Payments

Repairs/Maintenance/Gas

Public Transportation

Other Transportation Expenses

Vehicle Insurance

House Insurance

Furniture/Content Insurance

Life Insurance

Other Insurance Expenses

Other Expenses

Tax Information
What year did you last file a tax return?
Were you entitled to a refund or did you owe taxes?

Refund Owed Taxes Broke Even
Have you received the refund or did you pay the amount?

Yes No
Amount of refund or balance owing:
What was your spouse's approximate income last year?
Were you living at your current address when you filed the return?

Yes No
What was the address?

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Historical Information
Within the last 12 months, have you sold or disposed of or transferred any property (such as real estate, vehicles or cashed in an investment such as RRSP)?

Yes No
What property?
When did it happen?
Amount of proceeds?
What did you do with the funds?
Within the last 12 months have you made any large or lump sum payments to a creditor in excess of your regular payment?

Yes No
Please provide details:
Within the last 12 months have you had any property seized by a creditor or funds taken from an account?

Yes No
What property?
When did it happen?
Who seized it? (secured creditor)
Within the last 5 years (knowing yourself to be insolvent), have you sold, disposed of or transferred any property (such as real estate, vehicles or cashed in an investment such as an RRSP)?

Yes No
What property?
When did it happen?
Amount of proceeds?
What did you do with the funds?
Made any gifts in excess of $500.00 to anyone, including relatives?

Yes No
Please provide details including amounts and dates:
Has anyone left you an inheritance which you have not yet received or do you expect to receive any sums of money not related to your normal income in the next 12 months? (i.e. Lump sum payments from the government, lawsuit settlements, motor vehicle accident awards)

Yes No
Please provide details:
Additional Information
Are you involved in civil litigation from which you may receive monies or property? (i.e. vehicle accident claim, wrongful dismissal claim, labour standards claim, etc)

Yes No
Please provide details:
Are there any outstanding garnishments, wage assignments, judgments or writs against you now?

Yes No
Please provide details including amounts:
Do you have any other credit cards not listed on your debt list?

Yes No
Please provide details including amounts:
Have you obtained any new or continued to use credit in the last 3 month?

Yes No
Please provide details:
Does your husband or wife own any assets that you do not?

Yes No
Please provide details:
Have you received any lump sum payments or settlements in the last 12 months?

Yes No
Please provide details:
Have you paid alimony or maintenance payments (child or spousal support) during the last year?

Yes No
To whom paid?
Amount paid so far this year?
Is it by court order?

Yes No
Date of court order?

Month Day Year
Date
Do you bank with a financial institution to which you owe money (including overdraft, credit card, line of credit) or do you have any automatic debits or post-dated cheques for debt payments?

Yes No
Please provide details
Which financial institution to you currently bank with?
Fines or penalties imposed by the court (including traffic fines)?

Yes No
Recognizance or bail bond?

Yes No
Fraud, embezzlement or obtaining property by false pretenses?

Yes No
Employment insurance overpayments?

Yes No
Are your vehicles or other assets insured?

Yes No
Has anyone co-signed any of your outstanding debts?

Yes No
Please provide details:
Do you have a safety deposit box?

Yes No
Please provide location and contents:
Are you currently involved in a matrimonial property settlement?

Yes No
Are you storing any personal property which does not belong to you?

Yes No
Please provide details:
Only for Student Loans
Did you receive your degree/certificate?

Yes No
Attended school from:

Month Day Year
Date
Attended school to:

Month Day Year
Date
Area of study
Institution Attended
When did you receive your student loans?
Are you working in that field?
Any other information we should be aware of?
I certify that my answers are true and complete to the best of my knowledge.

Clear
Supporting Documents
Please provide the following documents (if applicable)

Identification Driver’s license, birth certificate, etc Copy of your insurance and registraztion for your vehicle(s) Copy of any vehicle loan agreements, leases, loans through finance companies and mortgage agreements Financial Statements of any businesses owned Recent copies of credit card statements, overdrafts and lines of credit Copies of investment statements (i.e. RRSP, RESP, TFSA, Canada Savings Bonds, Profit Sharing Plans, Stocks, Stock options, Shares, Term Deposits, GIC, etc.) Copy of your life insurance policy/policies A copy of yours and your spouses pay stub(s) Copy of garnishee, court order judgement, requirement to pay Copy of previous tax return/NOA Copy of land title
Please upload the documents

Browse Files

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Should be Empty:

Licensed Insolvency Trustee

Your Information

Spousal Information

Dependent Information

Business Information

Employment Information/History

Spouse’s Employment Information / History

Prior Insolvencies / Other

Assets

Secured Creditors

Unsecured Creditor

Monthly Income

Non-discretionary

Monthly Discretionary Expenses (Family Unit)

Tax Information

Historical Information

Additional Information

Only for Student Loans

Supporting Documents