Business affidavit form

In the matter of (insert estate number(s) or estate name(s) from the Unclaimed Funds Database) for unclaimed dividends held by the Receiver General, I swear or say under penalty of perjury:

1. That (insert the company’s name) is entitled to the unclaimed dividends specified in the claim attached hereto;
2. That I, (insert the name of the legal representative), am the legal representative of the business creditor to whom the funds held are payable;
3. That I have knowledge of the circumstances connected with this claim;
4. That I have reason to believe that the Receiver General for Canada holds unclaimed dividends to which (insert the company’s name) is entitled in the amount of $ (insert amount);
5. That (insert the company’s name) has not been reimbursed by a third party and the amounts are still owed;
6. That (insert the company’s name) is entitled to request payment of the unclaimed dividends pursuant to subsection 154(1) of the Bankruptcy and Insolvency Act;
7. That (insert the company’s name) claims the unclaimed dividends pursuant to subsection 154(2) of the Bankruptcy and Insolvency Act;
8. That (insert the company’s name) agrees and undertakes to indemnify Her Majesty and her officers, officials, employees and agents if it is determined that the company is not entitled to the funds;
9. That (insert the company’s name) has or had a place of business at (insert address from Unclaimed Funds Database); and
10. That the content of the attached Claim Form and supporting documents is accurate and true.

Sworn before me in the city of in the province of this day of , 20.