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?

Day Month 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:

Day Month Year
Date
Social Insurance Number *
Marital Status:

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

Yes No
Date of change:

Day Month Year
Date
Previous marital status:
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:

Day Month 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 blank if home address):

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date Started:

Day Month Year
Date
Date Closed:

Day Month 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:

Day Month 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:

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

Day Month 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:

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

Day Month 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/LIRA
Stocks
Bonds
Company or Co-op Shares
Securities: Other (Crypto Currency etc.)
Tools of the Trade
House/Condo/Town home
Mobile Home
Rental Property (Full Address)
Automobile #1 (Year/Make/Model)
Automobile #2 (Year/Make/Model)
Automobile #3 (Year/Make/Model)
Motorcycle (Year/Make/Model)
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
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?

Day Month 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
How much do you owe?
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:

Day Month Year
Date
Attended school to:

Day Month 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
Are you sure, you want to submit? *

Yes
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

Cancel of
VOLUNTARY SELF-IDENTIFICATION for:

Innovation, Science and Economic Development Canada Office of the Superintendent of Bankruptcy Canada
Do you consent to answering these questions? *

Yes No
What is your gender? *

Male Female Other I prefer not to answer.
Highest level of education? *

0-8 years Some high school High school diploma Some post-secondary Post-secondary certificate or diploma University degree I prefer not to answer.
Are you an Aboriginal person? (An Aboriginal person is a North American Indian or a member of a First Nation, a Métis or an Inuk (Inuit). North American Indians or members of a First Nation include status, treaty or registered Indians, as well as non-status and non-registered Indians.) *

Yes No I prefer not to answer.
If you wish to provide further details, please specify the group to which you belong.

North American Indian/First Nation Métis Inuit
Are you a person with a disability? (A person with disability has a long-term or recurring physical, mental, sensory, psychiatric or learning impairment and considers himself or herself to be disadvantaged by reason of that impairment, or believes that an employer or potential employer is likely to consider him or her to be disadvantaged in employment by reason of that impairment. Persons with disabilities are also those whose functional limitations owing to their impairment have been accommodated in their current job or workplace.) *

Yes No I prefer not to answer.
If you wish to provide further details, please select the boxes that apply to you

Co-ordination or dexterity (difficulty using hands or arms, for example, grasping or handling a stapler or using a keyboard) Mobility (difficulty moving around, for example, from one office to another or up and down stairs) Blind or visual impairment (unable to see or difficulty seeing) Deaf or hard of hearing (unable to hear or difficulty hearing) Speech impairment (unable to speak or difficulty speaking and being understood) Other disability (including learning disabilities, developmental disabilities and all other types of disabilities)(Please specify)
Are you a member of a visible minority group?(A member of a visible minority in Canada may be defined as someone (other than an Aboriginal person) who is non-white in colour/race, regardless of the place of birth.) *

Yes No I prefer not to answer.
If you wish to provide further details, please select the box(es) that best describes your origin

Black Chinese Filipino Japanese Korean South Asian/East Indian (including Indian from India; Bangladeshi; Pakistani; East Indian from Guyana, Trinidad, East Africa; etc.) Southeast Asian (including Burmese; Cambodian; Laotian; Thai; Vietnamese; etc.) Non-White West Asian, North African or Arab (including Egyptian; Libyan; Lebanese; Iranian; etc.) Non-White Latin American (including indigenous persons from Central and South America, etc.) Person of Mixed Origin (with one parent in one of the visible minority groups listed above
Your response to the self-identification questions (Section II) is collected under the authority of the Bankruptcy and Insolvency Act and will be stored in Personal Information Bank no. IC PPU 058 - Estate Files Under the Bankruptcy and Insolvency Act. This information will be used by the Office of the Superintendent of Bankruptcy (OSB) for statistical analysis, public policy research, and program development. Your response is voluntary and will remain confidential. Refusing to answer Section II will not negatively impact the processing of your file under the Bankruptcy and Insolvency Act. You may access, request correction or notation to your personal information by contacting the OSB. You further have the right to complain to the Privacy Commissioner of Canada respecting the handling of your personal information by the OSB.

I, the undersigned, do consent to the collection, disclosure, and use of my response to the self-identification questions by the OSB.
Signature *

Clear
PIF Submitted?

Yes
Should be Empty:

	Full Name	Date of Birth (DD/MM/YY)	Relationship	Primary Custody?	Lives at your residence?	Monthly Income
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7

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

VOLUNTARY SELF-IDENTIFICATION for: