The Debt Clinic of Canada

Send this duly filled-up form to us by fax or email for free evaluation of your options in dealing with your financial problem.

GENERAL INFORMATION
Name :
Address :
Telephone No. :
Date of Birth :
Email Address :
Name of Spouse :
No. of Children below 18 years of age :
Date of Birth :
Business Telephone Number :

BUDGET INFORMATION

MONTHLY INCOME
Gross Pay	Applicant :
	Spouse :
Net take-home pay	Applicant :
	Spouse :
Other Income
TOTAL NET INCOME (Net Take-home pay plus Other Income)

MONTHLY EXPENSES
Food :
Housing :
Utilities :
Clothing :
Medical :
Transportation :
Insurance :
Other major expenses(specify) :
Incidentals :
TOTAL MONTHLY EXPENSES :
TOTAL DISPOSABLE INCOME (subtract Monthly Expenses from Total Net Income) :

ADDITIONAL INFORMATION
1. Have you sold real estate property within the last 5 years?		Yes No
2. A) Have you withdrawn RRSPS within the last 12 months?		Yes No
B) If yes, how much?
3. A) Are you behind on some monthly payments?		Yes No
B) If yes, how many months?
4. Have you filed for bankrupcty before?		Yes No

ASSETS AND LIABILITIES INFORMATION

ASSETS:
House :
Automobile :
Furniture & Household Items :
Investments :
Others :


Total Value :

LIABILITIES:
Unsecured :
Credit Cards :
Personal loans :
Others :

Total Unsecured :

Secured :
First Mortgage :
Second Mortgage :
Car Loans :
Others :

Total Secured :
Grand Total :