Licensee Application Form

A. APPLICANT LICENSEE/FIRM INFORMATION

Name
Address
Telephone Number
Fax Number
E-Mail Address

Select one:

B. FILE/MATTER INFORMATION

Steps taken:

Name and licensee number of licensee responsible for file/matter

Number assigned by licensee/firm to file/matter

Reference on file

Type of file/matter (e.g., personal injury, real estate etc)if litigation file, specify style of cause, if real estate include address of property)

C. Client/Party Entitled Information

If more than one person is entitled to the funds, attach a separate sheet for each person and complete all questions for each person.

Full name of client and last known address

Full name of party entitled to funds (if different than client) and last known address

If client is a corporation, full name of person instructing licensee on file/matter

Last known telephone number of party entitled to funds

SIN or corporation number (if known) of party entitled to funds

Date of birth of party entitled to the funds CalendarToday

Male or female?

Driver’s licence number (if known) of party entitled to the funds

Any other information to identify person or to confirm validity of the person’s claim to funds (e.g. names, birthdates of children)

D. Trust Funds

Dollar amount of unclaimed funds
Date funds received by licensee in trust	CalendarToday
Date funds were last active	CalendarToday
Reason why funds were not paid out by licensee/firm to person(s) entitled,
Are funds subject to trust conditions or competing claims? (If yes, give complete details and attach relevant documents.)	Yes No
Are funds subject to trust conditions or competing claims? Details

E. ENTITLEMENT TO FUNDS NOT KNOWN.

Reason why entitlement to funds has not been determined (attach schedule if necessary)

F. EFFORTS MADE TO PAY OUT FUNDS

Attach copies of the documents that relate to the steps taken to pay out funds. (The steps listed below are examples of steps that a licensee/firm might take to pay out funds. A licensee/firm must demonstrate that all reasonable steps to locate the beneficiaries of the trust funds have been taken, prior to the application being approved.)

Note: If correspondence to party entitled has been returned, please include a copy of the returned envelope which should indicate reason for return.

Letters, Faxes, e-mails sent (attach copies) Yes No Date(s) Results/Comments

Phone calls made (provide telephone number(s) ) Yes No Date(s) Results/Comments

Driver’s licence search Yes No Date(s) Results/Comments

411.ca internet search Yes No Date(s) Results/Comments

Bell Canada Yes No Date(s) Results/Comments

Personal property (PPSA) search Yes No Date(s) Results/Comments

Title search Yes No Date(s) Results/Comments

Corporate search Yes No Date(s) Results/Comments

Steps taken: other Yes No Date(s) Results/Comments

Note: Section G must be completed.

G. The Society publishes a notice annually in The Ontario Gazette listing the names and last known address of every person entitled to money paid to the Society during the previous year. Publication of the name and address is not required, if:
      (i) Publication of the name or address breach a duty of confidentiality owed by you to the client/person entitled to the funds, or
      (ii) There are reasonable grounds for believing that the publication of the name or address will result in a significant risk or physical or psychological harm to the person whose name or address is published or to another person.

Should the name of the client or person entitled be exempt from publication in The Ontario Gazette?

If yes, please provide details

H. CERTIFICATION OF LICENSEE

I
of

in the Province of Ontario, certify that the information set out in this application, and in any attachments, is correct to the best of my knowledge and belief.

Date	CalendarToday
Signature