Unclaimed Dividends Claim Form s1

Unclaimed Dividends Claim Form Business Creditor

Estate name or estate number: ______(Name or number appearing in the Unclaimed Dividends Database)

Business Creditor Information

Name: ______Current address: ______City: ______Province: ______Postal code: ______Phone: ______ext. ______(daytime) ______(evening) Email: ______Status of company: Active Dissolved

Attached current Certificate of Compliance or equivalent

Legal Representative of Business Creditor

Name: ______Current address: ______City: ______Province: ______Postal code: ______Phone: ______ext. ______(daytime) ______(evening) Email: ______

Indicate relationship to business creditor:

Attached Letter of Authority, or equivalent documentation, establishing that you have the authority to submit this claim on behalf of the aforementioned business creditor.

If you are an authorized third party submitting a claim on behalf of the business creditor, provide the following information:

Name: ______Current address: ______City: ______Province: ______Postal code: ______Phone: ______ext. ______(daytime) ______(evening) Email: ______

Attached Power of Attorney or last will and testament establishing that you have the authority to submit this claim on behalf of the aforementioned business creditor.

In cases where the business creditor is now operating under a different name, provide the required information as applicable:

. The business creditor underwent a name change Attached copy of the Change of Name Registration Certificate or equivalent documentation (original or true certified copy)

. The business creditor has gone through a change of ownership Attached proof of amalgamation, or proof that the assets (including receivables and debts) were acquired by the successor (original or true certified copy)

. The business creditor operates under different names, one being the name appearing in the Unclaimed Dividends Database Attached printout of the company registry, or equivalent documentation, demonstrating that the company also operates under the name appearing in the Unclaimed Dividends Database (original or true certified copy)

Banking information

Direct deposit is the only method available for payments issued after January 1, 2015. Therefore, to receive a payment, provide the following information:

Name of financial institution: ______Address of financial institution: ______Financial institution no. (3 digits): ______Branch transit no. (5 digits): ______Name(s) of account holder(s): ______Bank account no.: ______SWIFT code (international payments only): ______IBAN no. (international payments only): ______

A void cheque OR a copy of a blank cheque must be attached to this form. Consent

I, the undersigned, consent to the Receiver General for Canada issuing my payments as indicated above, by direct deposit, to my bank account. I, the undersigned, have read the Privacy Notice and consent to the collection, use and disclosure of my personal information as outlined in the notice. To ensure prompt payment(s), I will notify the Receiver General for Canada of any changes to my banking information. I, the undersigned, confirm that all information provided above is correct.

Privacy Notice Your personal information is collected pursuant to the Financial Administration Act, ss. 17(1) and 35(2). The information is used and disclosed to the relevant federal program(s) and to your financial institution for direct deposit purposes. Direct deposit payments cannot be made without providing the information requested on this form. Personal information is protected in accordance with the provisions of the Privacy Act. Under the Act, individuals and businesses have a right to request access to and correct their personal information, if erroneous or incomplete. Personal information collected from this form is stored in the following Standard Personal Information Bank—IC-PSU-931 (Accounts Payable). For questions or comments regarding this privacy notice or for additional information about the administration of the Privacy Act at Industry Canada, please communicate with the Information and Privacy Rights Administration office at 613-952-2088. For more information on privacy issues and the Privacy Act in general, please consult with the Office of the Privacy Commissioner at 1-800-282-1376.

Signature of Applicant: ______Date (YYYY-MM-DD):______

Mailing the form

Forward the completed form, the required documentation, an affidavit and a cheque or money order for $30 (payable to the Receiver General for Canada) to:

Office of the Superintendent of Bankruptcy Financial Services Heritage Place 155 Queen Street, 4th Floor Ottawa ON K1A 0H5