Schwartz Levitsky Feldman Inc.
2300 Yonge Street, Suite 1500
Toronto ON M4P 1E4
Fax: (416) 784‑3025
Estate No.        
Court No.         
District of:        
Division No.         
Ontario
FORM 31
Proof of Claim
(Sections 50.1, 81.5, 81.6, Subsections 65.2(4), 81.2(1), 81.3(8), 81.4(8), 102(2), 124(2), 128(1),
and Paragraphs 51(1)(e) and 66.14(b) of the Act)
IN THE MATTER OF THE BANKRUPTCY / PROPOSAL/ RECEIVERSHIP OF

_______________________________________________________________________________________________
All notices or correspondence regarding this claim must be forwarded to the following address:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
	In the matter of the bankruptcy / proposal /receivership of _________________ of and the claim of ______________________________, creditor.
         I, _______________________________ (name of creditor or representative of the creditor), of the city of _______________ in the province of ______________, do hereby certify:

	1. That I am a creditor of the above named debtor (or I am ________________________ (position/title) of _________________________,  creditor).		

	2. That I have knowledge of all the circumstances connected with the claim referred to below.

	3. That the debtor was, at the date of bankruptcy / proposal /receivership, namely the __ day of _________ 20__, and still is, indebted to the creditor in the sum of $________________________, as specified in the statement of account (or affidavit) attached and marked Schedule "A", after deducting any counterclaims to which the debtor is entitled. (The attached statement of account or affidavit must specify the vouchers or other evidence in support of the claim.)

	4. (Check and complete appropriate category.)
Regarding the amount of $________________________, I do not claim a right to a priority.
(Set out on an attached sheet details to support priority claim.)

That in respect of this debt, I do not hold any assets of the debtor as security and 
(Check appropriate description.)
Regarding the amount of $ ________________________, I claim a right to a priority under section 136 of the Act. 
That I hereby make a claim under subsection 65.2(4) of the Act, particulars of which are as follows:
(Give full particulars of the claim, including the calculations upon which the claim is based.)
B. CLAIM OF LESSOR FOR DISCLAIMER OF A LEASE $________________________
C. SECURED CLAIM OF $________________________
 A. UNSECURED CLAIM OF $________________________

That in respect of this debt, I hold assets of the debtor valued at $__________________ as security, particulars of which are as follows:
(Give full particulars of the security, including the date on which the security was given and the value at which you assess the security, and attach a copy of the security documents.)
(other than as a customer contemplated by Section 262 of the Act)
That I hereby make a claim under subsection 81.2(1) of the Act for the unpaid amount of $________________
(Attach a copy of sales agreement and delivery receipts.)
D. CLAIM BY FARMER, FISHERMAN OR AQUACULTURIST OF $________________________

E. CLAIM BY WAGE EARNER OF $________________________
That I hereby make a claim under subsection 81.3(8) of the Act in the amount of $__________,
That I hereby make a claim under subsection 81.4(8) of the Act in the amount of $__________,

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FORM 31 ‑‑‑ Concluded
That I hereby make a claim under subsection 81.6 of the Act in the amount of $__________,

That I hereby make a claim under subsection 81.5 of the Act in the amount of $__________,

F. CLAIM BY EMPLOYEE FOR UNPAID AMOUNT REGARDING PENSION PLAN OF $________________________

G. CLAIM AGAINST DIRECTOR $__________

(To be completed when a proposal provides for the compromise of claims against directors.)
That I hereby make a claim under subsection 50(13) of the Act, particulars of which are as follows:
(Give full particulars of the claim, including the calculations upon which the claim is based.)
That I hereby make a claim as a customer for net equity as contemplated by section 262 of the Act, particulars of which are as follows:
(Give full particulars of the claim, including the calculations upon which the claim is based.)
H. CLAIM OF A CUSTOMER OF A BANKRUPT SECURITIES FIRM $__________

	5. That, to the best of my knowledge, I ___________(am/am not) (or the above‑named creditor ___________(is/is not)) related to the debtor within the meaning of section 4 of the Act, and ________(have/has/have not/has not) dealt with the debtor in a non‑arm's‑length manner.

	6. That the following are the payments that I have received from, and the credits that I have allowed to, and the transfers at undervalue within the meaning of subsection 2(1) of the Act that I have been privy to or a party to with the debtor within the three months (or, if the creditor and the debtor are related within the meaning of section 4 of the Act or were not dealing with each other at arm's length, within the 12 months) immediately before the date of the initial bankruptcy event within the meaning of Section 2 of the Act: (Provide details of payments, credits and transfers at undervalue.)
I request that a copy of the report filed by the trustee regarding the bankrupt’s application for discharge pursuant to subsection 170(1) of the Act be sent to the above address.
	7. (Applicable only in the case of the bankruptcy of an individual.)

Dated at ________________________________________, this ___________________ day of _________________________, ___________.
_________________________________
Witness
_________________________________

Creditor

Whenever the trustee reviews the financial situation of a bankrupt to redetermine whether or not the bankrupt is required to make payments under section 68 of the Act, I request to be informed, pursuant to paragraph 68(4) of the Act, of the new fixed amount or of the fact that there is no longer surplus income.
If an affidavit is attached, it must have been made before a person qualified to take affidavits.
E‑mail Address : 
Fax Number : 
Phone Number: 
______________________________
______________________________
______________________________
Subsection 201(1) of the Act provides severe penalties for making any false claim, proof, declaration or statement of account.

WARNINGS:
NOTE:
A trustee may, pursuant to subsection 128(3) of the Act, redeem a security on payment to the secured creditor of the debt or the value of the security as assessed, in a proof of security, by the secured creditor.
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