Abakhan & Associates Inc. - Trustees in Bankruptcy

Suite 1120 - 625 Howe Street, Vancouver, BC V6C 2T6
Tel: 604-689-4255 Fax: 604-689-4277 Toll Free (Mainland BC): 1-877-308-8877

Suite 414 - 1207 Douglas Street, Victoria, BC V8W 2E7
Tel: (250) 995-3122 Fax: (250) 483-1003 Toll Free (Vancouver Island): 1-866-995-3122

Suite 101 - 154 Quebec Street, Prince George, BC V2L 1W2
Tel: (250) 563-4635 Fax: (250) 563-4659 Toll Free (Mainland BC): 1-866-563-4635

Confidential Detailed Application
Please answer to the best of your knowledge. If you have any questions, please call us at (604) 689-4255 or Toll Free at 1-877-308-8877.
When you have filled out the information, print a copy of this form for your records and click on the Submit button at the bottom of this form.
Once we have received your information, we will contact you to make an appointment for your free initial consultation.

PERTINENT INFORMATION RELATING TO YOUR AFFAIRS

Surname:
Given Names:
Address:
City:
Province:
Postal Code:
Birth Date:	D M Y
Social Insurance No:

Telephone

Home:
Cell:
Fax:
Message:
Work:
Email:

EMPLOYMENT

Present Employer:
Address:
City:
Province:
Postal Code:
Phone:
Your Usual Occupation:
Employment Started:			D M Y
Unemployed Since:			D M Y

MARITAL STATUS

Status:
If married, is there a contract?
Date of Contract:			D M Y
Spouse's Surname:
Given Names:
Address:
City:
Province:
Postal Code:
Birth Date:			D M Y
Social Insurance No:

SPOUSE'S EMPLOYER

Employed By:
Address:
City:
Province:
Postal Code:
Phone:
Spouse's Occupation:
Employment Started:			D M Y
Unemployed Since:			D M Y

DEPENDENTS
List all dependents that rely on you for financial support

Full Name	Relationship	Date of Birth	Address (if different)	Annual Income
		D M Y		$
		D M Y		$
		D M Y		$
		D M Y		$
		D M Y		$

If over 18 years old, explain why they are still dependent:

SELF-EMPLOYMENT

Have you been self-employed in the past 5 years?
Type of Business:
Name of Business:
Principal Business Activity:
No. of Years in Operation:
Total Debt due to Business:	$
No. of Employees on Payroll:
Location of Payroll Register:

Within the past 5 years have you:

a) sold, disposed of or transferred any real estate?
Explanation:
b) made any gifts in excess of $500 to relatives or to others?
Explanation:

Within the past 12 months have you:

a) disposed of or transferred any of your assets?
Explanation:
b) made any payments to a creditor in excess of regular payments?
Explanation:
c) had any assets seized by any creditor?
Explanation:

Have you made arrangements to pay any credit creditors?
Explanation:

BUDGET INFORMATION

Monthly Income

Gross Pay - Applicant:	$
Gross Pay - Spouse:	$

Net Take-home Pay - Applicant:	$
Net Take-home Pay - Spouse:	$
Other Income:	$ Specify:
Other Income:	$ Specify:
Other Income:	$ Specify:
TOTAL MONTHLY INCOME:	$

Monthly Expenses

Food:	$
Housing:	$
Utilities:	$
Clothing:	$
Medical:	$
Transportation:	$
Insurance:	$
Other:	$ Specify:
Other:	$ Specify:
Other:	$ Specify:
Incidentals:	$
TOTAL MONTHLY EXPENSES:	$

Total Disposable Income
(TOTAL MONTHLY INCOME LESS TOTAL MONTHLY EXPENSES)

STATEMENT OF AFFAIRS

Cash

On Hand:		$
Savings Acct. No:	Name of Bank:	$
	Address:
Chequing Acct. No:	Name of Bank:	$
	Address:

Cash Surrender Value of Life Insurance

Name of Company:		$
Policy No:
Beneficiary:

Stocks, bonds, RRSP's and Investments (Specify)

	$
	$
	$
	$
	$

Real Property

House:	$
Cottage:	$
Other (i.e. land):	$

Motorized and Recreational Vehicles

	Year & Model	Licence No.	Serial No.	Registered To:	Value
Car					$
					$
Truck					$
					$
Others (Specify)
					$
					$
					$

Furniture, appliances and household effects:	$
Personal effects:	$
Estimated tax refund:	$

Other Assets (Specify):

	$
	$
	$
	$

TOTAL VALUE OF ALL ASSETS:

LIABILITIES - DEBTS (Please type complete name and address of all creditors)

Name	Full Address	Account No.	Amount Owing	Reason
			$
			$
			$
			$
			$
			$
			$
			$
			$
			$

TOTAL OF ALL LIABILITIES - DEBTS:

SUPPLEMENTARY INFORMATION

Employment History
Your employers for the past two years. Show each period when Employment Insurance was received.

Employer:
Address:
City:
Province:
Postal Code:
Phone:
Occupation:
Employment Started:
Employment Ended:

Employer:
Address:
City:
Province:
Postal Code:
Phone:
Occupation:
Employment Started:
Employment Ended:

Employer:
Address:
City:
Province:
Postal Code:
Phone:
Occupation:
Employment Started:
Employment Ended:

Income Tax Information

Year when last filed:
Amount Owing:	$
Refund Received:	$
Refund Expected:	$
Have you discounted your previous return?
Address at time last return was filed (if different from present address)

Details of Alimony or Maintenance
Indicate the amount paid and beneficiary.

Name	Address	Amount
		$
		$

Details of any present garnishments or attachments

Details of any wage deductions

Have you any credit cards?
(If yes, please specify)

Description	Account Number

Have you received or do you expect to receive an inheritance?
(If yes, please explain)

Are you bonded in your present position?
(If yes, please explain)

Have you ever been bankrupt before?

When	Where	Name of Trustee

Have you obtained any credit in the last 3 months?
(If yes, please explain)

Has anyone guaranteed some of your debts?
(If yes, please explain)

If you own property

Sole or Joint Ownership?
Name of joint owner(s):

Approximate resale value of your property:

Name of Mortgage Holder	Amount Owing
	$
	$
	$
TOTAL AMOUNT OWING:	$

If you rent

Address of main residence	Number of Months	Rent paid	Property Tax paid	Name of Landlord
		$

Describe briefly the circumstances that caused your financial problems

Please indicate the source of your referral (lawyer, accountant, friend, yellow pages, advertising, etc.)

CERTIFICATION

I hereby certify that the information contained in this application is true and complete in every respect and fully discloses the state of my affairs. In addition, I recognize that any income in excess of reasonable cost of living must be paid to the trustee for the general benefit of the creditors.


Signature of Applicant (if form is printed)	Date

Please bring the following to your initial consultation:

Completed questionnaire
Two pieces of identification (i.e. Birth Certificate and one other piece of identification such as a Driver's License or SIN card)
All of your credit cards (including those that have a "zero" balance) as well as any supplementary credit cards in the possession of your spouse or others
Your most recent credit card statements
Copy of the last tax return filed by you or on your behalf
Your most recent pay stub
Motor vehicle registrations for all vehicles registered in your name
Life insurance policies
RRSP statements, bonds, stocks, or other marketable securities owned by you
Property tax assessment of any real estate owned by you
Documents relating to the sale of all real estate owned by you during the past 5 years
Copy of your Separation Agreement and/or Divorce Order (if applicable)
All documents relating to any legal actions you are involved in (i.e. writs, judgments, garnishments, wage assignments, etc.)

Please print a copy of this form for your records BEFORE submitting.