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AgriStability Direct Deposit Registration Form

You can use either the Web version or the PDF version (139 KB).

Please complete, print and send the form by mail.

Mail the completed form to:

AgriStability
P.O. Box 3200 Station Main
Winnipeg, Manitoba R3C 5R7

Questions: Please call AgriStability at 1-866-367-8506.

Protected B when completed

Part 1 - Participant Identification

Complete one form for each farming operation that has been assigned a Participant Identification Number (PIN).

Complete this section if you participate in AgriStability as an individual producer.

Surname:

Given Name:

Initial(s):

Street Address (Apartment Number, Rural Route, or P.O. Box):

City, Town:

Province/Territory:

Postal Code:

Telephone:

Participant Identification Number (PIN):

Complete this section if you participate in AgriStability as an entity (corporations, co-operatives, communal organizations, band farms, and limited partnerships).

Entity Name:

Surname of Authorized Representative:

Given Name of Authorized Representative:

Initial(s):

Street Address (Apartment Number, Rural Route, or P.O. Box):

City, Town:

Province/Territory:

Postal Code:

Telephone:

Participant Identification Number (PIN):

Part 2 - Bank Account Information

Attach a blank cheque with "VOID" written on it, and your AgriStability benefits will be deposited to your chequing account. You do not have to complete the section below.

Have your financial institution complete this section if you want your AgriStability benefits deposited to your savings account. Note: You cannot use an AgriInvest account for AgriStability direct deposit purposes.

Branch Number:

Institution Number:

Account Number:

Name(s) of account holder(s):

Financial institution's stamp here (required if no void cheque attached)

Part 3 - Privacy Notice

The information on this form is collected under the authority of sections 33 and 34 of the Financial Administration Act and will be used for the purposes of administering AgriStability benefits to you by direct deposit. Your personal information is protected in accordance with the Privacy Act and Sections 10 and 11 of the Farm Income Protection Act, and is shared with Public Services and Procurement Canada and your financial institution to administer payment to you. The collection, use and disclosure of your personal information for the purposes of direct deposit is described in further detail in Accounts Payable Personal Information Bank PSU 931. The information may also be used for statistical or evaluation purposes. Individuals have the right to request access and correction to their personal information. Should you have any questions concerning your privacy, please contact: Access to Information and Privacy Office, Agriculture and Agri-Food Canada,1341 Baseline Road, Ottawa ON K1A 0C5 or by email at aafc.atip-aiprp.aac@canada.ca.

Part 4 - Consent

You or an authorized representative (if this registration form is for an entity) must sign this form. An authorized representative is an owner, officer or director of the entity.

As the participant/authorized signatory, I:

consent to the AgriStability Administration issuing payments by direct deposit;
have read the Privacy Notice and consent to share my personal information on this form with Public Works and Government Services Canada and my financial institution;
understand that I am responsible for notifying the Administration of any changes to my banking information; and
confirm that all information provided on this form is correct.

Participant Identification Number (PIN):

Date (YYYYMMDD):

Signature of Applicant