APPLICATION


For KSAI Completion

Applicant(s)'s Name

Sign-up Date and Time


Source of file & Type of filing

Sign-up location


Payment term and EFT starting date

Document Checklist (Please indicate documents provided by Application)
    Attached Available @ Time of signing Notes      
I.D. Passport, citizenship or PR card, driver's license, birth certificate
Social Insurance Number card/paper, or T1013
Real Property Property tax bill and Current mortgage statement(s)
Trust ledger from lawyer after property is sold
Investment Most recent account statement (RRSP, RRIF, RDSP, RESP, TFSA, CSB, stock, mutual fund, etc.)
Copy of insurance policy showing policy detail and beneficiary
Vehicle Ownership, insurance and lease/finance document
Transaction Sale/transfer of assets documents done in past 5 years, marriage separation agreement, etc.
Taxes Most recent CRA notice of assessment or T1 general
Company's statement of account for director’s liabilities (RT and RP)
Income Proof of income (paystubs, tax return, bank statement etc.)
Proof of spouse's income and/or Child tax benefit statement
Proof of support payment including spousal/child or social assistance (ODSP)
Proof of non-discretionary expenses (spouse or child support payment, child care, medical, court fine/penalty, etc.)
Creditors Credit card statements/credit report/ loan statements / statement of claims/judgement etc.
Business List of tools of trade, registration document
Payment 3rd party guarantee, banking info/void chq
blank blank
Personal Data

Applicant's Last Name

Spouse's/joint applicant's Last Name


Middle Name, if applicable

Middle Name, if applicable


First name

First name


Other name/ Also known as

Other name/ Also known as


S.I.N.

S.I.N.


Date of Birth (DD/MM/YYYY)

Date of Birth (DD/MM/YYYY)


Gender
Gender

Marital Status

Specify month and year of event if it occured in the last 5 years (DD/MM/YYYY)


Home phone #


Cellphone #

Cellphone #


Work #

Work #


Email address

Email address


Home Address

Street

City


Postal Code

In current address since (DD/MM/YYYY)


Usual Occupation

Usual Occupation


Level of Education

Level of Education


Number of persons in household family unit, including debtor?


Number of persons 17 years of age or less? (Specify below)
Name Date of Birth Relationship
Assets
  Applicant Spouse Comments
Cash on hand
Household furnishing and appliances
Jewellery or personal effects
Life insurance policies, Term or Whole Life Policy (c.s.v):
Investments: Pension / Stock / Mutual Fund / Profit Sharing / TFSA / CSB / RESP and Others, please provide current statements:
Total investment in RRSP/RRIF, name of the financial institution
contributions in RRSP/RRIF during last 12 months
Tax refund or any money expected to be received Within 12 months

Real property Address


Present market value: $

Source of present market value


Ownership:  
% of applicant's Ownership

Make:

Model:


Automobiles: VIN#


Value: $

Year:


  Type Value $
Recreational vehicles/equipment
Tools Of trade (value and list)
Other Assets– Business Share or loan receivables, deposit for purchasing property
Reasons for financial difficulty
UNSECURED DEBTS
  Name of Creditor and Account number Balance(in $) Address and Comments (e.g. business, guaranteed, etc.)
Applicant Spouse Joint
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

SECURED DEBTS (mortgages, car loans/ lease etc.) :
  Name of Creditors and Account number Balance(in $) Address and Comments (e.g. business, guaranteed, etc.)
Applicant Spouse Joint
13.
14.
15.
OTHER

Prior proposal/bankruptcy?
Applicant Spouse
Trustee’s name: Trustee’s name:
Filing type: Proposal or Bankruptcy Filing type: Proposal or Bankruptcy
Estate No Estate No
Reason(s) for filing proposal/bankruptcy: Reason(s) for filing proposal/bankruptcy:

Business Owned By Debtor (Applicant or Spouse) in the past 5 years
AppIicant owned business?
Business name Nature of business
Type of ownership: Proprietorship / Partnership / Incorporate HST & RP # (if applicable)
Starting Date Closing Date
Causes, if closed
Assets(details) Financial statements/tax returns (please submit the latest document)

Employment history in the past 2 years:
Applicant Spouse joint Application
Emloyer's Name and Address Started Ended Emloyer's Name and Address Started Ended
Is above mentioned employer related with you?

Transaction
Within the 12 months prior to the date of the initial bankruptcy event, have you, either in Canada or elsewhere:
  Applicant
Yes/No
Spouse
Yes/No
Sold/disposed of/transferred/re-financed any property?
If yes, please provide trust ledger or account statement, and details including date of the transaction, address of the property/business, monetary value and what the proceeds were used for, etc.
Have you paid back any debts to family members? If Yes (provided details): When, Whom and why?
Made any excess payments to creditors? If yes, details with amount
Had any assets seized by creditors? If yes, details with amount
Within The 5 Years Prior TO The Date Of The Initial Bankruptcy Event, Have You, Either in Canada Or Elsewhere
Sold/disposed of/transferred/re-financed any property? If yes, please provide trust ledger or account statement, and details including date of the transaction, address of the property/business, monetary value and what the proceeds were used for, etc.
Made any gift to relatives or others in excess Of $500? If yes (provide details When and what)?
Do you expect to receive extra sum of money in the next 12 months? If yes, details with amount
Monthly Income & Expenses Budget

Family Income
  Applicant Spouse Other members
Net employment income
Net pension/Annuities
Net child support
Net employment insurance benefits
Net Social assistance
Self-employed income, Gross:
Child tax benefit
Other income (rental or family support)
Total monthly net income:

Monthly Non- Discretionary Expenses:
  Applicant Spouse Other members
Child Support payments
Spousal support payments
Child care
Medical condition expenses
Fine/penalties imposed by the Court
Debts where stay has been lifted
Other expenses
Total non-discretionary expenses

Expenses of the whole family unit
Housing Expenses Family Expenses
Rent/mortgage/hypothec Food Grocery
Property taxes/condo fees Laundry/dry cleaning
Heating/gas/oil Grooming/toiletries
Telephone Clothing
Cable Other
Hydro Transportation Expenses
Water Car lease/payment
Furniture Repair/maintenance/gas
Other Public transportation
Personal Expenses Other
Smoking Insurance Expenses
Alcohol Vehicle
Dining/lunches/restaurants House
Entertainment/Sports Furniture/contents
Gifts/charitable donations Life Insurance
Allowances Other
Other Payements
Non-recoverable medical expenses Payments to the estate
Prescriptions To secured Creditors (other than mortgage and Vehicle)
Dental
Other Other
Notes:
1 2 3 4 5 6 7 8

KSA 2020 by JL