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 NameMiddle NameLast Name
Also Known As (Alias):

First NameMiddle NameLast Name
Residential Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When did you move in?

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Home Phone Number:

Area CodePhone Number
Cell Phone Number:

Area CodePhone Number
Work Phone Number:

Area CodePhone Number
Ext
Primary Email
example@example.com
Secondary Email
example@example.com
Date of Birth:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Social Insurance Number
Marital Status:
Has your marital status changed in the last 5 years?
Date of change:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Previous marital status:
Emergency Contact Name & Relationship:
Emergency Contact Phone Number:

Area CodePhone Number
Spousal Information
Will your spouse also be filing a bankruptcy or proposal?
Spouses Name:

First NameMiddle NameLast Name
Spouse Also Known As (Alias):

First NameMiddle NameLast Name
Spouse Home Phone Number:

Area CodePhone Number
Spouse Cell Phone Number:

Area CodePhone Number
Spouse Work Phone Number:

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

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Spouse Social Insurance Number:
Spouse Gender:
Spouse Education:
Dependent Information
Do you have children?

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?
Type of Business:
Name of Business:
Nature of Business:
Address of Business (Leave blank if home address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Started:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Date Closed:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Name of Directors, Officers, Partners:
Does the business have and assets or accounts receivable?
Please list:
Have all of the required GST returns been filed?
GST Number:
Have the required T4's been prepared?
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

CityState / Province

Postal / Zip Code
Start Date:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
If you are unemployed or retired, since when?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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

Rows	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

CityState / Province

Postal / Zip Code
Start Date:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Is your spouse unemployed or retired, since when?

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
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)?
What was the cause of the previous bankrupty?
Date of Bankruptcy:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Name of Trustee:
Date of Discharge:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Bankruptcy Location:
Have you filed for a proposal before (either in Canada or elsewhere)?
Did you receive your certificate of full performance?
How did you hear about us? (Check all that apply):
Cause of your financial difficulties? (check all that apply):
Assets

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

Rows	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.

Rows	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.

Rows	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.

Rows	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.

Rows	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

Rows	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?
Have you received the refund or did you pay the amount?
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?
What was the address?

Street Address

Street Address Line 2

CityState / 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)?
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?
Please provide details:
Within the last 12 months have you had any property seized by a creditor or funds taken from an account?
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)?
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?
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)
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)
Please provide details:
Are there any outstanding garnishments, wage assignments, judgments or writs against you now?
Please provide details including amounts:
Do you have any other credit cards not listed on your debt list?
Please provide details including amounts:
Have you obtained any new or continued to use credit in the last 3 month?
Please provide details:
Does your husband or wife own any assets that you do not?
Please provide details:
Have you received any lump sum payments or settlements in the last 12 months?
Please provide details:
Have you paid alimony or maintenance payments (child or spousal support) during the last year?
To whom paid?
Amount paid so far this year?
Is it by court order?
Date of court order?

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
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?
Please provide details
Which financial institution to you currently bank with?
Fines or penalties imposed by the court (including traffic fines)?
How much do you owe?
Recognizance or bail bond?
Fraud, embezzlement or obtaining property by false pretenses?
Employment insurance overpayments?
Are your vehicles or other assets insured?
Has anyone co-signed any of your outstanding debts?
Please provide details:
Do you have a safety deposit box?
Please provide location and contents:
Are you currently involved in a matrimonial property settlement?
Are you storing any personal property which does not belong to you?
Please provide details:
Only for Student Loans
Did you receive your degree/certificate?
Attended school from:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Attended school to:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
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.
Are you sure, you want to submit?
Supporting Documents
Please provide the following documents (if applicable)
Please upload the documents

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VOLUNTARY SELF-IDENTIFICATION for:

Innovation, Science and Economic Development Canada Office of the Superintendent of Bankruptcy Canada
Do you consent to answering these questions?
What is your gender?
Highest level of education?
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.)
If you wish to provide further details, please specify the group to which you belong.
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.)
If you wish to provide further details, please select the boxes that apply to you

Other
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.)
If you wish to provide further details, please select the box(es) that best describes your origin

Other
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
PIF Submitted?
Should be Empty:

Rows	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: