REPRESENTED PERSON INFORMATION FOR THE OFFICE OF THE PUBLIC TRUSTEE “The represented person is herein referred to as the “Person' [SECTION A - PERSONAL INFORMATION |Family Name Given Name Middle Name [Maiden Name: [Social Insurance Number: Mate Female [Also Known As: [Date of Bithaucenostex [Place of Birth: Marita status: [1 single (1 married C1] pivorced C widower) C1 common-taw C1 separated [Treaty Band or Disc. No. [PLACEMENT INFORMATION IName and Address of the Facility IPhone Number: IName and Address for the Contact Person IPhone Number: [Placement date: I place of residence has changed in the last sic years, please list past places of residence. CURRENT CAREGIVER: | ame and Address of person who Is currently handling the PERSON=s finances: [Phone Number: [Does the PERSON have any outstanding assets or debts which require immediate attention? Please indicat te: [WILL INFORMATION (only if will was prepared) fie ae riginal Will now |ooes the PERSON have a Will? _ [If yes, please provide name and address of the person who has the [Phone Number: IName and address of Executor named in the Wil: IPhone Number: [SECTION B - INFORMATION ABOUT SPOUSE OF THE PERSON Family Wi Given Name Middle Name Maiden Name: dna neice Dremale IMaiing Address: lphone Number: Date of Birth: soanonre Pace of Birth [Social insurance Number: lt deceased, provide: Date of Death: suanonrrex Place of Death: is spouse employed? id they fle a tax retum forthe last loo they claim a child tax ereit? calendar year? Cres Ono ’ Over Ono Oves Ono lwas spouse legally married to the [Date of Marriage: [Place of Marriage: PERSON? hureoarven ives 0. no | spouse ive common-law, what date did they start ving together? tsouwoayreer Page 1 of 4 OVER[SECTION C- MARITAL INFORMATION IF MARRIED MORE THAN ONCE IMaiden Name of Former Spouse Given Name |Date of Mariage: [Date of Divorce or Separation: jrenioayrese Wereoervee [Place of Marriage: [Date of Birth uneoayresr [Date Spouse Died: toanoayvaw [Place of Death: [SECTION D - INFORMATION ABOUT THE CHILDREN OF THE PERSON 1H. |Last Name Given Name Middle [Social Insurance Number: IMaiing Address 10 has custody? IPhone No. |Date of Birth: | Date of Death: [Sex Naturat C1 custom Adopted C1 regatly Adopted Hennomrewr—|ioestoyres [Cntaie LFemale jircustom or legally adopted, at what age? bz. |Last Name Given Name Midate [Social Insurance Number: IMaiing Address ho has custody? Phone No. |oate or itn: [Date otDeath: [sex oO oO pecoywent”” | rmoyres Natural C1 cuss a Cale C1 remale If.custom or legally adopted, at what age? tom Adopted L] Legatly Adopted ls. |Last Name Given Name Middle {Social Insurance Number: ing Address Ino has custody? f PreneNe. Ene” [aeons [oe Natural C1 custom Adopted C1 regatty Adopted itale 1 Female |icustom ortogally adopted, at what age? [ast Name Given Name idle [socia insurance Number: Mating Aderess wo has custody? me No. ae of i e [sex Prone Ne. MResroee” — |ienooncs Naturat CI custom Adopted C1 Legal Adoptes vale F Female jr custom or loglly adopted, at what age? kb. [Last Name Given Name Middle social insurance Number: hating Address [who nas custody? fee ee CD niaturat C1 custom Adopted C1 vegaty Adopted Tviale F1 Femate |ircustom or legally adopted, at what age? J [Last Name Given Name Middle social insurance Number: lating Adaress| ho has custody? Prone No. Matec [usnmores OE Naturat CI custom adopted C1 tegaty Adopted Divale O1 Female [rcustom or tegally adopted, at what age? Jare any othe above chien disables? LC] yes Fo tyes, pease expan: list adationa children on @ separate sheet and attach fo this form. Please indicate if another tis attached. Ove: One lPage 2 of 4 OVER[SECTION E- INCOME INFORMATION Did the PERSON fea tx retum? |ityes, forwhat year? [Is there a refund or tax owing? mount ves L1no retina 0 tax owing P IPREVIOUS EMPLOYERS (List employers for previous 2 years) Name and Address of Employer period Worked [From To: IName and Address of Employer: [period Worked [From: To [DOES THE PERSON RECEIVE ANY OF THE FOLLOWING BENEFITS? [Benefit [ves |No [Amount [Benefit es _|No amount INWT Senior Citizen & Is lsun Lite Is lols Age Security [Retirement \cPP Disability and/or Is Ichita Tax Is |CPP Retirement (Creat dows Pension Is [Unemployment Is lOrphans Benefit Is Other, specity is |SECTION F - GENERAL INFORMATION INFORMATION ABOUT PARENTS: lLast Name of Father Given Name Middle [Date of Birth: Nenevoervew |Date of Death: neanoayver IMaiting Address IPhone Number IMaiden Name of Mother Given Name Middle [Date of Birth: enmoerrew |Date of Death: nearer IMaling Address IPhone Number INFORMATION ABOUT BROTHERS & SISTERS (Living or deceased) 1. |Last Name Given Name Middle [Date of Birth veneoeirew [Date of Death: nortan IMailing Address IPhone Number 2. Last Name Given Name Middle [Date of Birth verevorrrew |Date of Death: noanoayest IMailing Address IPhone Number ls. Last Name Given Name Middle [Date of Birth erewayrea [Date of Death: nosntmear IMailing Address IPhone Number [4. |Last Name Given Name Middle [Date of Birth erevoarrear [Date of Death: nowoayvear IMailing Address IPhone Number ls. Last Name Given Name Middle [Date of Birth vereayresr [Date of Death: moana IMailing Address IPhone Number List adttonal brothers and sisters on a separate sheet and attach to this form JPtease incicae if another tists attached. LC] ves C1 no Page 3 of 4 OVER[BANK ACCOUNTS JBank Accounts? _|irYes, List Account No), Branch Name(s) and Location(s Ores a [Give the amount in the account if known: ILIFE INSURANCE [Does the PERSON |r Yes, List Name and Address of insurance Company: have tie insurance? Beneficiary: C1 None Named 1 Named ves Lno IREAL ESTATE: Does the PERSON own andlor lease any property? Lano’ ome yes, give tga! descrston an ie elas Yes, ve legal description (LovBlockPan cased [Elem [hetkindofbueng son tnd (StzerTyp0 of Fishinghitns): 2 Tleand Lend |LIHAP House [P° sides there now’ Csquater |Clsquater tinue? Dives 1 no tyes, wth whom uatter quater CO-OP SHARES/STOCKS/CANADA SAVINGS BONDS [Does the PERSON |If Yes, with whom (particulars): have any? ves. no PERSONAL ASSETS: (Cars, snowmobiles, furniture, guns, traps, etc) IName of Asset: Location: ILIST OUTSTANDING DEBTS: (Attach statements if available) IName lAddress lAmount SECTION G - COMPLETION OF FORM |Form Completed by (Name): joccupation: IMaling Address: lenone Number [signature Date \Retationship: [The following items should be enclosed with this form: IMait To: IOFFICE OF THE PUBLIC TRUSTEE Csi cortcates for the PERSON, Spouse and Least wit and —_ [Government of the NT Children of the PERSON Testament P.O. Box 1320 Couplicate certfcate of Tite for land or copy Mortgage and Yellowknife, NT X4A 2L9 l.can Clete nee, Clamee pomeer Sate meee Canites) _ |T0ll-free #1-866-535-0423 (nw only) Fax #867- 873-0184 7.copy orincome tax retunsforprioryears — L1share |certincate(s) TD sociat insurance card, Passport, credit card, bank books, monthly statements or invoices Page 4 of4