Used to claim past due arrears owed by an individual for a specified time period. This is required if you wish to register as a debtor with the program and have missed payments in the past. This ensures that we know exactly what time period you have missed payments so we can collect those payments more efficiently. You are required to have this document sworn before a Commissioner for Oaths in and for the Province of Alberta.

Notice to users:

This site uses JavaScript code to ensure that personal information entered into fill & print PDF forms is not displayed to subsequent users of the computer. This requires that any computer on which these forms are to be completed must have JavaScript turned on. Print only forms are available for printing if JavaScript cannot be turned on.

Unless you expect to need more than one browser session to complete the form, we recommend that you set Acrobat Reader NOT to keep forms data temporarily available on disk. To change this setting, click Edit, then Preferences, then Forms in Acrobat or Acrobat Reader and uncheck the item labeled "Keep forms data temporarily available on disk".