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					                                        KPMG INC.
                               FINANCIAL ADVISORY SERVICES
                                     INTERVIEW FORM

In order that we may review your financial status and provide you with all possible options available
to you depending upon your income, assets, and liabilities, please complete the attached Interview
Form in detail. The completion of this form is for the initial free interview and does not commit you to
any of the options that will be explained.


If applicable, please provide the following information/documents when submitting this application form:

- Driver’s License/Picture Identification, and one other piece (i.e. Care Card)
- Previous Bankruptcy Discharge Papers and/or Consumer Proposal Certificate of Full Performance
- Ownership proof and Insurance papers for all vehicles ICBC Registration Papers)       
- If you own real estate (i.e. house, property, mobile home), the most recent Notice of Assessment and a
  letter of opinion as to the current value of the real estate is required.
- Any document with regard to any legal actions that you are involved in, such as writs, judgments, wage
  garnishees, wage assignments, marriage settlements, etc.
- Credit Union Bank Account Statement          
- Personal Insurance Policy or last annual statement
- Last pay stubs or E.I. stubs
- Previous year income tax Notice of Assessment & copy of previous tax return filed           
- RRSP accounts/statements (current & redeemed previous year) 
- Other investment accounts (GIC, CSB, RESP), Bank Statements  
- Creditor addresses and account numbers and statements
- All Credit Cards (even cards with no balance owing)
- Independent evidence of value of vehicles owned (i.e. car dealer’s business card with value written on it)
- If you own a Limited company, please provide copy of recent financial statements and corporate tax return








                                                                                           KPMG Interview Form   Page 1
                                                         PERSONAL INFORMATION

SELF                                                                         SPOUSE
Full Legal Name:                                                              Full Legal Name:

_________________________________________________________                     __________________________________________________________
Last                       First                       M iddle                Last                       First                        M iddle
Marital Status - (Specify month and year of change in
                                                                                  SPOUSAL INFORMATION IS IMPERATIVE TO ENSURE THAT
marital status                                                                       YOUR CHILD TAX BENEFITS, GST AND TAXES ARE
Date:_____________________________________                                                     CALCULATED PROPERLY
 Married                 Single               Common-law
 Separated               Divorced              Widowed
S.I.N Number                       Birth date       Y       M          D      S.I.N Number                           Birth date       Y       M      D


Home Phone                         Business Phone                             Home Phone                             Business Phone
                                   Cell Phone                                                                        Cell Phone

Occupation (Position)                                                         Occupation (Position)


Employer Name                                                                 Employer Name


Employer Address                                                              Employer Address


                                                          Postal Code                                                                     Postal Code


Employed Since                     Y            M          D                  Employed Since                         Y        M           D




Home Address
                                                                           For Office Use Only                     Interviewer:

                                                                                                                   Date:



                                                                           Signup Date:                      Time:                    Location:
Resided At Address Since:__________________________________


                                                                           Summary:___ Consumer Proposal:___ Ordinary: ___ Div/Proposal___
M ailing Address if Different from Above:                                  File to be entered for:   M r. Only_____ M s. Only _____ Joint______

                                                                           Fee Arrangements: ___________________________________________


                                                                           ____________    ___Down, _____ ___________ x ___ ___ ____ M onths



Dependents residing with you: Number under age 17: __________              Notes:
                                                                           ___________________________________________________________________
Date of birth               Name                        Relationship
(y/m/d)                                                                    ___________________________________________________________________


_________________________________________________                          ___________________________________________________________________

_________________________________________________                          *****************************************************************************
                                                                           *****
_________________________________________________                          Who Referred you to KPM G: Yellow Pages________ Internet ______
                                                                           Newspaper Ad (Name Paper) _____________________________________
_________________________________________________                          Radio Ad ________       Lawyer ________     Previous Client ________
                                                                           Other, please specify _____________________________________________




                                                                                                                            KPMG Interview Form    Page 2
KPMG Interview Form   Page 3
BUSINESS INFORMATION

Have you, during the last 5 years, owned or had an interest in a business? SELF:         Yes             No
                                                                           SPOUSE:       Yes             No
If yes, please provide details below:
                                           Self                                      Spouse
                           Business #1            Business #2          Business #1          Business #2
Proprietorship,
Partnership, or Ltd. Co.
Partner Name(s)

Business Name

Business Number

Position Held

Your Share (%)

Date Business Started

Date Business Ceased

Reason For Closure

Approx what % of
your debts are from
the business
Have Business Taxes &
GST been Filed To Date
List of Business Assets:
                 Asset                             Value of Asset                     Location of Asset




For the current tax year, list all employers and indicate the date you started and ceased employment.
If there are periods when you received EI or Social Assistance Benefits, show each period separately.
SELF
Employer’s Name                    Employer’s Address               Commenced               Terminated




SPOUSE
Employer’s Name                    Employer’s Address               Commenced               Terminated




                                                                                           KPMG Interview Form   Page 4
                                                   BUDGET INFORMATION


MONTHLY INCOME                                 $            MONTHLY                                      $
                                                            NON DISCRETIONARY EXPENSES
Net earnings from employment:         (Self)                Child support payments
                                  (Spouse)                  Spousal support payments
Net Pension/Annuities:                                      Child care expenses
(Self)
                                  (Spouse)                  Medical condition expenses
Net OAS:                                                    Prescriptions/Dental Expenses
(Self)
                                  (Spouse)                  Fines/Penalties imposed by the court
Net Child Support:                    (Self)                Employment-Related Expenses (provide
                                                            T2200)
                                 (Spouse)                   TOTAL - NON DISCRETIONARY EXPENSES
Net Spousal Support:                  (Self)
                                  (Spouse)
Net EI Benefits:                      (Self)                For Office Use
                                  (Spouse)                  Net Family Income

Net Social Assistance:                                      Less Superintendent Standard
(Self)
                                  (Spouse)                  Less Non Discretionary Expenses

Gross Self Employment Income:                               Net Income
(Self)
                                  (Spouse)                  Div ided by 50% (Surplus Income)

Child Tax Benefit:                    (Self)                % of Surplus:                His:

                                 (Spouse)                                              Hers:

Other Income (i.e. Rental)
                         TOTAL NET INCOME:


MONTHLY EXPENSES                                            MONTHLY EXPENSES

Rent/Mortgage                                               Grooming/Toiletries
Property Taxes/Condo Fees                                   Clothing
Heating/Gas/Oil                                             Car Lease/Car Loan Payments
Telephone/Internet                                          Repair/Maintenance/Gas
Cable                                                       Public Transportation
Hydro                                                       Transportation Cost
Water                                                       Vehicle Insurance
Smoking                                                     House Insurance
Alcohol                                                     Furniture/Contents Insurance
Dining/Lunches/Restaurants                                  Life Insurance
Entertainment/Sports                                        To the Estate
Gifts/Charitable Donations                                  To Secured Creditor
Allowances                                                  To Spouses Creditor’s
Food/Grocery                                                Other:
Laundry/Dry Cleaning                                        Other:


                                                                                                   KPMG Interview Form   Page 5
                                                                                  TOTAL MONTHLY EXPENSES:




REASON(S) FOR FINANCIAL DIFFICULTY:




HAVE YOU PREVIOUSLY FILED A BANKRUPTCY OR PROPOSAL IN CANADA OR ELSEWHERE? (SPECIFY)

APPLICANT                                Y         N                SPOUSE                                        Y         N
Trustee’s Name                                                      Trustee’s Name
Bankruptcy Date                                                     Bankruptcy Date
Bankrupt Discharge Date                                             Bankrupt Discharge Date
Proposal Date                                                       Proposal Date
Result of Proposal                                                  Result of Proposal
Place Filed                                                         Place Filed
Estate No.                                                          Estate No.
                          For Office Use: Insolvency Searches Completed: ____________ Date: _________________________
                                For Office Use: PPSA Search Completed: _______________ Date: ______________
                                                          Assets - Worksheet

Fill in a dollar value for the assets you own (anywhere in the world) (i.e: what you would get for the assets if sold
        in a garage sale/auction). Transfer the total from the worksheet to the applicable column on page 6.

HOUSEHOLD GOODS                                   Value              TOOLS OF THE TRADE (List)                            Value
(i.e. furniture, appliances, dishes,     $                                                                         $
electronics, clothing)
e,


PAINTINGS/PRINTS/COINS                  $



SPORTING EQUIPMENT
                                        $


ANTIQUES (DESCRIPTION)                  $


JEWELLERY                               $
                                        $
COMPUTER (copy of contract)
Is it a DELL Computer Yes  No 


        TOTAL Household Goods                                                         TOTAL Tools of Trade

                                                                                                                    KPMG Interview Form   Page 6
ASSETS: (Assets owned anywhere in the world)
Please value the assets at liquidation cost

Asset Description                                                                                                Estimate
                                                                                Present   Exempt   Pledged           to
                                                                                 Value                            Realize
Cash on Hand                                                                $


Household goods and effects                                                 $
(Amount from worksheet)


Tools of the Trade                                                          $
(Amount from worksheet)


Life Insurance Policy:                                                      $
Carrier Name: _______________________________________
Whole ________ or Term Life ________
Beneficiary ________________________CashValue________
Pension Plans                                                               $
(supply letter from Pension Plan proving locked-in)
Plan Name:___________________________________________
Address:  ___________________________________________

Credit Union Membership/Patronage Shares                                    $
(supply copy of statement showing value of these shares)


Accounts Receivable                                                         $
From Whom: _________________________________________

Property- Address and Legal Description:                                    $
_______________________________________________________
_______________________________________________________
_______________________________________________________
Joint ________ (supply copy of Property Assessment)
Year/Make/Model of Automobile:                                              $
_______________________________________________________
Serial #________________________________________________
Registered Owner:_____________________________________
Mileage:___________________Condition:_________________
Year/Make/Model of Automobile:                                              $
_______________________________________________________
Serial #________________________________________________
Registered Owner:_____________________________________
Mileage:___________________Condition:_________________
Other: (i.e. Boat, Trailer, Snowmobile, M otorbike, etc., Please Specify)   $



Other: (i.e. Boat, Trailer, Snowmobile, M otorbike, etc., Please Specify)   $




                                                                                                       KPMG Interview Form   Page 7
SECURED CREDITORS

HAVE YOU BORROWED MONEY ON, OR PLEDGED ANY OF YOUR ASSETS?
(provide copy of security documents)
YES_____________ No________________  If yes, indicate below:

  Name and Address of Creditor      Amount             Type       Present Value           SELF     SPOUSE
                                    of Loan         of Security     of Security




COMMON CREDITORS

       Name and Address                   Account                 Amount
                                                                                           SELF     SPOUSE
          of Creditor                     Number                  Of Debt
                                 SIN #
                                 #
                                 Tel#
                                 DL#
                                 SIN#




                                                                    KPMG Interview Form   Page 8
UNSECURED CREDITORS
        NOTE: TO PREVENT ANY DELAYS IN PROCESSING THIS APPLICATION, PLEASE ENSURE THAT COMPLETE
         ADDRESSES, POSTAL CODES AND ACCOUNT NUMBERS ARE LISTED.


                                                   Account                        Debt
    Name and Address of Creditor                                                                       SELF   SPOUSE
                                                   Number                       Amount




                                                                            KPMG Interview Form   Page 9
KPMG Interview Form   Page 10
LIST OF UNSECURED CREDITORS – CONT’D



                                                          Account                           Debt
      Name and Address of Creditor
                                                                                                                 SELF   SPOUSE
                                                          Number                          Amount




OTHER DEBTS
If you co-signed or guaranteed any debts for anyone complete the following:
 Creditor’s Name and Address                                Amount            Borrower’s Name and Address




                                                                                     KPMG Interview Form   Page 11
Have you any debts arising from the following:
                                                                      YES                        NO
                                                               SELF         SPOUSE       SELF          SPOUSE
 Fine or penalty imposed by the Court
 Recognizance of bail bond
 Fraud, Embezzlement, Misappropriation
 Defalcation while acting in a Fiduciary Capacity
 Misrepresentation
 Obtaining property by false pretense or fraudulent



Pertinent Information


 A) Have you sold, transferred, disposed, or given away any of your assets in the past 12 months either in
    Canada or elsewhere? (i.e. Real Estate, investments, RRSP’s, vehicles, household goods, etc.)
    Yes  No  If yes, explain and provide date




 B) Have you made payments in excess of regular payments to a creditor in the past 12 months either in
    Canada or elsewhere? Yes  No  If yes, explain and provide date




 C) Have you had any assets seized by any creditor within the past 12 months either in Canada or
    elsewhere? Yes  No        If yes, explain and provide date




 D) Within the past 5 years, did you sell or transfer any assets in Canada or elsewhere? (i.e. Real Estate,
    RRSP’s, Investments, vehicles, household goods, etc.) Yes  No  If yes, explain and provide
 date




 E) Within the past 5 years have you given any gifts to relatives or others
    valued at $500.00 or more in Canada or elsewhere? Yes  No  If yes, explain and provide date




 F) Are you expecting to receive any sums of money which are not related to your normal income, or
    any other property within the next 12 months? Yes  No     If yes, explain




 G) Do you owe money to a bank? (i.e. overdraft/line of credit) Yes  No            If yes, explain



                                                                                         KPMG Interview Form   Page 12
General

1. Please list banks that you currently use:
   Bank                Address                 City          Postal Code                      Account #




2. Are any bank accounts being garnished? Yes  No               If yes, state by whom and name of bank




3. Are you making or receiving alimony or maintenance payments?
   Yes  No  If yes, explain




4. Have you made any arrangements to continue to pay any creditors?
   Yes  No     If yes, explain




5. Were you, or are you, involved in lawsuits from which you may receive money or property?
   Yes  No       If yes, explain




6. Have you, or will you or your spouse receive an inheritance?
   Yes  No        If yes, explain



7. Have you or your spouse signed a Wage Assignment? Yes  No              If yes, explain



8. Do you or your spouse have judgments against you? Yes  No             If yes, explain



9. Have you used credit within the last 3 months? Yes  No         If yes, explain
   (i.e. which store, what purchased, amount of purchase, reason for purchase)



10. Are your wages being garnished? Yes  No           If yes, state by whom and for how
    much each pay day)




                                                                                       KPMG Interview Form   Page 13
Do you have any credit cards: Yes  No 
        List all credit cards         Account Number          Received     Destroyed          Spouses Card




Tax Information

 Last tax return filed (Year):                             Refund Amount:
 Has your marital status changed from the last return?
 Yes  No          If yes, provide date of change:
 What is your marital status to be claimed on your next income tax return
 Single      Married         Common-law  Separated          Divorced      Widowed 
 Do you have a safety deposit box? Yes  No  If yes, provide name of bank
 Did you use an RRSP for a down payment on a home that has not been repaid: Yes  No 
 GST Rebate Amount:                                Received by: Self     Spouse 

Office Use: Assignment of Post Tax Return Yes  No 

Student Loan Information

 Course Taken:                                  Name of Institution:

 Date Loan Received:                            Date Last Attended School:




I hereby certify that the information contained in the application form and in documents
attached thereto, are true, correct, and complete in every respect and fully disclose the state of
my assets liabilities, income and expenses. In addition, I recognize that a portion of my income
in excess of reasonable cost of living must be paid to the Trustee for the general benefit of my
creditors.


      ____________________________________________                       _____________________________
      Signature of Applicant                                             Date


      ____________________________________________                       _____________________________
      Signature of Joint Applicant                                       Date

                                                                                       KPMG Interview Form   Page 14

				
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