Application for Mediation

You can use either the Web version or another version of the form from the Alternative Formats section.

Please complete, print and send the form by mail or fax to your region or closest region.

Please mail to:

Regional Office responsible for Saskatchewan, Manitoba, British Columbia, Alberta, Nunavut, Northwest Territories and Yukon Territories

Agriculture and Agri-Food Canada
Farm Debt Mediation Service
301-2010 12th Avenue
Regina, Saskatchewan
S4P 4K7

Fax: 306-780-7353

Regional Office responsible for Ontario

Agriculture and Agri-Food Canada
Career Focus Program
P.O. Box 57000
Research Centre, 850 Lincoln Road
Fredericton, New Brunswick
E38 6C2

Fax: 506-452-4975

Quebec

Agriculture and Agri-Food Canada
Farm Debt Mediation Service
Jules-Dallaire Complex
2828 Laurier Blvd - Room 640
Quebec, Quebec
G1V 0B9

Fax: 418-648-2439

Regional Office responsible for Newfoundland and Labrador, Nova Scotia, New Brunswick and Prince Edward Island

Agriculture and Agri-Food Canada
Career Focus Program
P.O. Box 57000
Research Centre, 850 Lincoln Road
Fredericton, New Brunswick
E3B 6C2

Fax: 506-452-4975

Protected when completed.

Section 5 of the Farm Debt Mediation Act

The information you provide on this document is collected by Agriculture and Agri-Food Canada under the authority of the Farm Debt Mediation Act for the purpose of facilitating financial arrangements between farmers and their creditors. Personal information will be protected under the provisions of the Privacy Act and will be stored in Personal Information Bank AAFC/P-PU-227. Information may be accessible or protected as required under the provisions of the Access to Information Act.


of









Type of application:

Eligibility requirements

  1. You must be "engaged in farming for commercial purposes", ie. the applicant produces products for sale and not solely for their own personal use.
  2. You must be insolvent and indicate which of the following best describes your current financial situation:
Notice of Intent to Realize on Security

If yes, identify the originator:






2. Other Secured Creditors:
(A secured creditor is a creditor who holds some or all your assets, including money owed to you, as a security for his/her loan to you and such property may be seized if you have defaulted in repayment of your loan to him/her.)

Name and full mailing address
including postal code
Telephone number (Ext.) Fax number Estimated balance owing

Ext.
Ext.
Ext.
Ext.
Ext.

3. Unsecured Creditors:
(An unsecured creditor is a creditor who does not hold any of your assets as security for payment of his/her loan and has no other recourse but to sue you in order to have the defaulted loan paid.)

Name and full mailing address
including postal code
Telephone number (Ext.)Fax numberEstimated balance owing
Ext.
Ext.
Ext.
Ext.
Ext.
List of all assets
Cash $

Marketable securities

Accounts receivables

Livestock – type and quantity













Grain, produce, forage – type and quantity











Farm supplies

Quota

Land, buildings and improvements – legal description









Machinery and equipment – description

























Other assets – description





I / we, the undersigned, hereby authorize Agriculture and Agri-Food Canada, its employees, agents and contractors, to:

  1. request and obtain any information of a financial nature concerning my/our farming operations at

  2. have access to any and all records, books, papers, and other documentation concerning my/our financial affairs (including all security documents); and
  3. release a factual statement of my/our financial affairs to my/our creditors participating in any Mediation Meeting;

all for the purpose of conducting an examination of my/our current financial affairs and/or arriving at a financial arrangement(s) with my/our creditor(s) pursuant to the Farm Debt Mediation Act.


I / we certify that the information contained herein is true and complete to the best of my knowledge.

Dated this day of (year) at .


(Where farmer is a person or partnership)

Farmer signature (by hand only)

Farmer signature (by hand only)

Farmer signature (by hand only)

OR


(Where farmer is a company or cooperative)

Officer signature (by hand only)

Corporate seal

Officer signature (by hand only)




Alternative Formats

Help with Alternative Formats

Application for Mediation (PDF version, 696 KB)

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