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Personal Information

First name

Middle name

Last name

Email *

Phone *

Have you ever filed for bankruptcy in Canada?

Date of Birth *

Employed or Self-Employed?

Current Employer

Positon at Employment

At Current Job Since

Company Name

Business Type

Date Business Started

Monthly Income

Bi-weekly Paycheck

Do you have a spouse, ex-spouse or children? *

Spouse Name

Spouse Date of Birth

Spouse Monthly Income

Spouse Bi-weekly Paycheck

Ex-Spouse Name

Ex-Spouse Date of Birth

Child 1 Name

Child 1 Date of Birth

Child 2 Name

Child 2 Date of Birth

Child 3 Name

Child 3 Date of Birth

Do you receive Child Tax Benefit?

Child Tax Beneift Amount

Address

Street Address

Address Line 2

Province

Postal Code

At this address since?

Expenses

Rent/Mortgage Amount (Monthly)

Hydro/Water/Gas Amount (Monthly)

Do you smoke cigarettes?

Amount spent on dining out (Monthly)

Any medical expenses that are not covered by an insurance plan?

How much do you spend on groceries per month?

How much monthly for laundry/dry cleaning?

How much monthly for grooming/toiletries?

Do you own a car?

Car Year

Car Make

Car Payments

How much is your auto insurance per month?

Amount spent on gas/auto repairs per month?

Any other insurance expenses? Life? Tenant?

Assets

Do you have any savings in the bank?

Do you own any investments

Do you own or partially own any property?

Do you have a life insurance policy?

Insurance Company Name and Details

Financial

Which bank are you currently with

Do you owe that bank anything?

Have you transferred any assets within the last 12 months?

Do you expect to receive any sums of money outside of your normal income within the next 12 months?

Do you have a safety deposit box? If so, where?

Does anyone officially owe you money (documented)?

Please include a full list of all your creditors and amounts owed

Creditor

Amount Owed

York Credit Services

(647)302-3328

York Credit Services Toronto

Visit Us in Scarborough

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A Debt Specialist will call you soon to review your options.