Full Name

Phone *

Email Address *

Who referred you to us?

What is the name of the business?

City

Province

Postal code

What is the website of the business?

What is the main activity of the business?

What is the legal form of the business?

How many owners are there of the business?

What is the revenue for the business in the last completed fiscal year?

$

What was the last year in which a corporate tax return was filed for the business?

How much corporate tax is outstanding?

$

Is the business up to date on filing GST returns?

Yes

No

Approximately how much is outstanding for GST?

$

Is the business up to date on the filing of provincial sales tax (PST) returns?

Yes

No

N/A

Approximately how much is outstanding for PST?

$

Is the business up to date on the filing of payroll withholding returns?

Yes

No

Approximately how much is owing for payroll withholdings?

$

Approximately how much is owing for the Current Liabilities?

$

What type of Long Term Liabilities does the business have?

Approximately how much is owing for the Long Term Liabilities?

$

Has the corporation signed corporate guarantees for the debts of any other business or person?

Yes

No

Have any of the owners of the business or any other party signed guarantees regarding the business or any other entity or person (e.g. bank loans or suppliers)?

Yes

No

Does the company lease or own its premises?

Lease

Own

What is the status of lease payments for the premises?

What is the approximate value of the assets?

$

Are any of the Current Assets or Fixed Assets secured by financing?

Yes

No

How much is owed on the secured loans/leases?

$

Is the business currently involved in any litigation either as a plaintiff or a defendant?

Yes

No

What would you estimate is your level of enthusiasm to continue the business if you can solve its current financial problems?

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