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25%
Referred By
Do you rent or own?
Rent
Own
Personal Information
First Name
Middle Name
Last Name
Email
Phone
Date of Birth
Have you ever filed for bankruptcy in Canada?
Yes
No
Monthly Income
Bi-weekly Paycheck
Employment Status
Employed
Self-Employed
Employer Name
Job Title
Work Address
Marital Status
Single
Married
Common Law
Separated
Divorced
Spouse Name
Spouse Date of Birth
Spouse Monthly Income
Spouse Bi-weekly Paycheck
Do you have children?
Yes
No
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?
Yes
No
Child Tax Benefit Amount
Street Address
City
Province
Select a Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
At this Address Since
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Expenses
Rent/Mortgage Amount (Monthly)
Hydro/Water/Gas Amount (Monthly)
Do you smoke cigarettes?
Yes
No
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?
Any other expenses
Expense Name
Expense Amount
Do you own a car?
Yes
No
Car Make
Car Model
Car Year
Car Payments
Leased
Financed
Paid Off
How much is your auto insurance per month?
Amount spent on gas/auto repairs per month?
Any other insurance expenses? Life? Tenant?
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Assets
Do you have any savings in the bank?
Yes
No
Do you own any investments?
Yes
No
Do you own or partially own any property?
Yes
No
Do you have a life insurance policy?
Yes
No
Insurance Company Name and Details
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Financial
Which bank are you currently with?
Do you owe that bank anything?
Have you transferred any assets within the last 12 months?
Yes
No
Do you expect to receive any sums of money outside of your normal income within the next 12 months?
Yes
No
Do you have a safety deposit box? If so, where?
Does anyone officially owe you money (documented)?
Yes
No
Please include a full list of all your creditors and amounts owed
Creditor
Amount Owed
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