TAX-DEBT Canada Inc. Canada

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DEBT Registration Form

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FOR OFFICE USE ONLY
PREPARED BY:	FILE TYPE:	SERVICE LOCATION:
DATE OF ASSESSMENT:	DATE OF SIGN UP:	PAYMENTS:
REFERRAL SOURCE:	JOINT FILLING: Yes No

NAME OF DEPENDANT	AGE	DATE OF BIRTH	RELATIONSHIP
NUMBER OF PERSONS IN HOUSEHOlD FAMILY UNIT, INCLUDING THE APPLICANT:

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ASSETS

DESCRIPTION

VALUE FOR APPLICANT

VALUE FOR SPOUSE

EXEMPT?

ENC. BY

COMMENTS

CASH

HOUSEHOLD FURNITURE & EFFECTS

JEWELLERY OR PERSONAL EFFECT

C.S. V. OF INSURANCE POLICIES

RRSPs / RRIF / LIRA (submit copies)

CONT. IN LAST 12 MONTHS? AMT?

RESP's (submit copies)

SHARES / BONDS / INVESTMENTS (submit copies)

HOUSE

Description:

Title Holders:

Secured Creditor:

HOUSE

Description:

Title Holders:

Secured Creditor:

MOTOR VEHICLES

Year:	Make:
Model:	Trim:

Style:

KM:

Year:	Make:
Model:	Trim:

Style:

KM:

SNOWMOBILE / MOTORCYCLE / BOAT

TRAILER / CAMPER

RECREATIONAL EQUIPMENT / ATV

TAX REFUNDS

BUSINESS ASSETS

ACCOUNTS RECEIVABLE

TOOLS

OTHER (specify):

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OTHER DEBT INFORMATION
LOANS CO-SIGNED OR GUARANTEED BY APPLICANT:
LENDER'S NAME:
ADDRESS:

BORROWER'S NAME:
ADDRESS:

IS THE PARTY BANKRUPT?
BUSINESS OR PERSONAL DEBT?
TYPE Of BUSINESS:
LOANS CO-SIGNED OR GUARANTEED BY SPOUSE:
LENDER'S NAME:
ADDRESS:

BORROWER'S NAME:
ADDRESS:

IS THE PARTY BANKRUPT?
BUSINESS OR PERSONAL DEBT?
TYPE Of BUSINESS:

HAVE YOU PREVIOUSLY FILED A BANKRUPTCY OR PROPOSAL IN CANADA OR ELSEWHERE? (SPECIFY)
APPLICANT Yes No TRUSTEE'S NAME: BANKRUPTCY DATE: BANKRUPT DISCHARGE DATE: PROPOSAL DATE: RESULT Of PROPOSAL: PLACE FILED: ESTATE NO.:	SPOUSE Yes No TRUSTEE'S NAME: BANKRUPTCY DATE: BANKRUPT DISCHARGE DATE: PROPOSAL DATE: RESULT Of PROPOSAL: PLACE FILED: ESTATE NO.:

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TRANSACTIONS
DESCRIPTION	APPLICANT	SPOUSE
HAVE YOU SOLD, DISPOSED OR TRANSFERRED ANY ASSETS, CASHED RRSP'S OR CHANGED THE NAMED BENEFICIARY ON A LIFE INSURANCE POLICY IN THE LAST 12 MONTHS? (Provide Details)	Yes No	Yes No
HAVE YOU MADE PAYMENTS IN EXCESS OF THE REGULAR AMOUNT TO CREDITORS IN THE LAST 12 MONTHS? (Provide Details)	Yes No	Yes No
HAVE YOU HAD ANY ASSETS SEIZED OR GARNISHEED BY A CREDITOR IN THE LAST 12 MONTHS? (Provide Details)	Yes No	Yes No
HAVE YOU SOLD, DISPOSED OR TRANSFERRED ANY REAL PROPERTY OR OTHER ASSETS IN THE PAST FIVE YEARS? (Provide Details) INSOLVENT AT THE TIME: Yes No	Yes No	Yes No
HAVE YOU MADE ANY GIFTS TO RELATIVES OR OTHERS IN EXCESS OF $500.00 IN PAST 5 YEARS WHILE YOU KNEW YOURSELF TO BE INSOLVENT? (Provide Details) INSOLVENT AT THE TIME: Yes No	Yes No	Yes No
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 (INCLUDING INHERITANCE)? (Provide Details)	Yes No	Yes No
HAVE YOU BEEN OR ARE YOU INVOLVED IN CIVIL LITIGATION FROM WHICH YOU MAY RECEIVE MONIES OR PROPERTY? (Provide Details)	Yes No	Yes No
HAVE YOU MADE ARRANGEMENTS TO CONTINUE TO PAY ANY CREDITORS AFTER FILING? (Provide Details)	Yes No	Yes No

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INCOME TAX INFORMATION
LIST ALL YOUR EMPLOYERS, SHOWING THE DATES STARTED AND TERMINATED, FOR THE PAST TWO YEARS.
EMPLOYER'S NAME AND ADDRESS	DATE STARTED	DATE ENDED



SPOUSE'S EMPLOYERS AND EMPLOYMENT INSURANCE (EI) PERIODS FOR THE PAST TWO YEARS:
EMPLOYER'S NAME AND ADDRESS	DATE STARTED	DATE ENDED

APPLICANT'S TAX INFORMATION
YEAR LAST RETURN FILED:
AMOUNT OWING:
REFUND RECEIVED:
REFUND PENDING:

SPOUSE'S TAX INFORMATION
YEAR LAST RETURN FILED:
AMOUNT OWING:
REFUND RECEIVED:
REFUND PENDING:

DID YOU PAY CHILD OR SPOUSAL SUPPORT DURING THE PAST YEAR?

Yes

IF YES, TO WHOM?

ADDRESS:

AMOUNT PAID:

**IF CHILD OR SPOUSAL SUPPORT PAYMENTS ARE BEING PAID ATTACH A COPY OF THE COURT ORDER**

DATE OF SEPARATION:

BANK ACCOUNT INFORMATION

BANK:

ADDRESS:

ACCOUNT NUMBER:

JOINT

BANK:

ADDRESS:

ACCOUNT NUMBER:

JOINT

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BUSINESS
APPLICANT OWNED BUSINESS WITHIN THE LAST 5 YEARS?	Yes No
BUSINESS NAME:
ADDRESS:
TYPE OF OWNERSHIP:
TYPE OF BUSINESS:
ARE YOU A DIRECTOR?	Yes No
NAMES OF PARTNERS / DIRECTORS:
WHEN STARTED:	WHEN CEASED:
IS THE CORPORATION BANKRUPT?	Yes No
DOES THE BUSINESS:
HAVE EMPLOYEES OR SUB-CONTRACTORS?	Yes No
OWE ANY WAGES TO EMPLOYEES?	Yes No
OWE ANY SOURCE DEDUCTIONS ON WAGES?	Yes No
Other Details:
SPOUSE OWNED BUSINESS WITHIN THE LAST 5 YEARS?	Yes No
BUSINESS NAME:
ADDRESS:
TYPE OF OWNERSHIP:
TYPE OF BUSINESS:
ARE YOU A DIRECTOR?	Yes No
NAMES OF PARTNERS / DIRECTORS:
WHEN STARTED:	WHEN CEASED:
IS THE CORPORATION BANKRUPT?	Yes No
DOES THE BUSINESS:
HAVE EMPLOYEES OR SUB-CONTRACTORS?	Yes No
OWE ANY WAGES TO EMPLOYEES?	Yes No
OWE ANY SOURCE DEDUCTIONS ON WAGES?	Yes No
Other Details:

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MONTHLY INCOME AND EXPENSES STATEMENT

MONTHLY INCOME (NET)	APPLICANT	SPOUSE	OTHER HOUSEHOLD MEMBERS
EMPLOYMENT INCOME
PENSION / ANNUITIES
CHILD SUPPORT
SPOUSAL SUPPORT
EMPLOYMENT INSURANCE
SOCIAL ASSISTANCE
SELF EMPLOYMENT INCOME
RENTAL INCOME
UNIVERSAL CHILD CARE
CHILD TAX BENEFITS
OTHER:
SUBTOTAL
TOTAL INCOME

HOUSING EXPENSES	AMOUNT
RENT/MORTGAGE PAYMENT
PROP. TAXES / CONDO FEES
HEAT / FUEL OIL
TELEPHONE
CABLE
HYDRO / ELECTRICITY
WATER
FURNITURE
HOUSEHOLD MAINTENANCE
OTHER:
SUBTOTAL

PERSONAL EXPENSES	AMOUNT
SMOKING
ALCOHOL
DINING/LUNCHES/RESTAURANTS
ENTERTAINMENT/SPORTS
GIFTS/CHARITABLE DONATIONS
ALLOWANCES
NEWSPAPERS/MAGAZINES
OTHER:
SUBTOTAL

MEDICAL EXPENSES	AMOUNT
PRESCRIPTIONS
DENTAL
OTHER:
SUBTOTAL

MONTHLY NON-DISCRETIONARY	AMOUNT
CHILD SUPPOORT 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 FILED
BUSINESS RELATED EXPENSES
OTHER:
SUBTOTAL

LIVING EXPENSES	AMOUNT
FOOD / GROCERY
LAUNDRY/ DRY CLEANING
GROOMING/TOILETRIES
CLOTHING
OTHER:
SUBTOTAL

TRANSPORTATION EXPENSES	AMOUNT
CAR LEASE / FINANCE PAYMENTS
REPAIR/MAINTENANCE/GAS
PUBLIC TRANSPORTATION
OTHER:
SUBTOTAL

INSURANCE EXPENSES	AMOUNT
VEHICLE
HOUSE
FURNITURE / CONTENTS
LIFE INSURANCE
OTHER:
SUBTOTAL

PAYMENTS	AMOUNT
VOLUNTARY PAYMENTS
SURPLUS INCOME PAYMENTS
SETTLEMENT ON ASSETS
TO SECURED CREDITOR
OTHER:
SUBTOTAL

TOTAL EXPENSES
SURPLUS / DEFICIENCY (Total Combined Income Less Total Expenses)

REASONS FOR FINANCIAL DIFFICULTY (please check all that apply)
Over extension of credit	Inconsistent employment	Mismanagement of finances
Reduction in income	Job loss	Marital separation/relationship breakdown
Medical / related issues	Gambling	Insolvency of co-signor
Other(Specify)
DESCRIBE IN YOUR OWN WORDS WHY YOU NEED FINANCIAL HELP:

DEBTS
	BALANCE			DEBT TYPE
CREDITOR NAME AND ADDRESS	APPLICANT	SPOUSE	JOINT	CONSUMER	BUSINESS
1.

Secured by:
Account # / Comments:
2.

Secured by:
Account # / Comments:
3.

Secured by:
Account # / Comments:
4.

Secured by:
Account # / Comments:
5.

Secured by:
Account # / Comments:
6.

Secured by:
Account # / Comments:
7.

Secured by:
Account # / Comments:
8.

Secured by:
Account # / Comments:
9.

Secured by:
Account # / Comments:
10.

Secured by:
Account # / Comments:
TOTALS:

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DO YOU HAVE ANY DEBTS ARISING FROM BELOW:	APPLICANT	SPOUSE
FINE OR PENALTY IMPOSED BY COURT? (INCLUDING ASSAULT)	Yes No	Yes No
RECOGNIZANCE OR BAIL BOND?	Yes No	Yes No
ALIMONY?	Yes No	Yes No
MAINTENANCE OF AFFILIATION ORDER?	Yes No	Yes No
MAINTENANCE OF SUPPORT OF SEPARATED FAMILY?	Yes No	Yes No
FRAUD?	Yes No	Yes No
EMBEZZLEMENT?	Yes No	Yes No
MISAPPROPRIATION?	Yes No	Yes No
DEFALCATION WHILE ACTING IN A FIDUCIARY CAPACITY?	Yes No	Yes No
PROPERTY OR SERVICES OBTAINED BY FALSE MEANS/FRAUD?	Yes No	Yes No
STUDENT LOANS OUTSTANDING (indicate last day of program)	Yes No	Yes No
PLEASE PROVIDE DETAILS: