Debt Settlement Request Form

Step 1

Step 1
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Step 2

Step 2
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Step 3

Step 3

List your unsecured debts

Complete one row for each of your unsecured consumer debts. List the approximate dollar amount for each of the following types of unsecured debts; credit cards, personal loans (excluding student loans) lines of credit, monies owing to phone companies, cable and internet service providers, monies owing in connection with goods or service provided to you and the date of your last payment or default on each debt. Click here for an example of a completed Step 1.

Name of specific creditor	Dollar amount of individual unsecured debt	Date of last payment or default (YYYY/MM)

List your unsecured debt by category: Total amount owing by category

	Category	Approximate Dollar Amount Owing

	Credit cards

	Personal loans (excluding student loans)

	Lines of credit

	Cable, internet and telephone

	Other:





Total

Miscellaneous

Are you on social assistance? Yes No Are you employed? Yes No

If so, does your annual income from employment exceed $30,000? Yes No

Do you have any outstanding judgments against you? If yes, for how much?

Are your wages currently being garnisheed? Yes No

Do you own any real property (house, condo, townhouse, cottage) that you own in your own name? If yes, what is the equity in your real estate?

Occupation

Your contact information

Your name E-mail address

Home address

City Province Postal Code

Daytime phone number Evening phone number



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