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AgriStability Program Appeal Submission Form

You can use either the Web version below or the PDF (163 KB).

Please complete, print and send the form by mail or fax.

Protected B when complete

Section 1 - Participant information

Participant identification

Name

Participant Identification Number (PIN):

Telephone number:

Fax number:

Representative information

Complete this section if you would like someone else to provide or receive additional information on your behalf regarding your appeal.

Name

Business name:

Telephone number:

Fax number:

Indicate the program year(s) for which you are submitting the appeal:

2012

2013

2014

2015

2016

2017

2018

2019

Date:

If this is for a partnership or combined operation, provide the names and PINs of all appellants. For corporations, provide the name and the PIN of the corporation.

List of the names and PINs of all appellants
Name of appellant	Participant Identification Number (PIN)
Name of Co-appellant 1	Participant Identification Number 1
Name of Co-appellant 2	Participant Identification Number 2
Name of Co-appellant 3	Participant Identification Number 3
Name of Co-appellant 4	Participant Identification Number 4
Name of Co-appellant 5	Participant Identification Number 5
Name of Co-appellant 6	Participant Identification Number 6
Name of Co-appellant 7	Participant Identification Number 7
Name of Co-appellant 8	Participant Identification Number 8

Section 2 - Nature of appeal

You may request an appeal if:

you feel we did not correctly apply AgriStability program rules in processing your form or adjustment. The program rules are outlined in the Guidelines and Handbook. Explain below which program rules you feel we did not correctly apply to your form.
you missed a deadline because of exceptional circumstances beyond your control. Identify the missed deadline and the reason for missing it below.

See AgriStability Appeal Process for more information on the appeal process.

Section 3 - Documentation

List of documents and number of pages
Number the front page of any supporting documents you are providing and list them in numerical order below.	Number of pages
Title of document 11)	Number of pages 1
Title of document 22)	Number of pages 2
Title of document 33)	Number of pages 3
Title of document 44)	Number of pages 4
Title of document 55)	Number of pages 5
Title of document 66)	Number of pages 6
Title of document 77)	Number of pages 7
Title of document 88)	Number of pages 8
Title of document 99)	Number of pages 9
Title of document 1010)	Number of pages 10

Total number of pages including this page:

Section 4 - Send your completed form

Mail or fax

AgriStability Program Appeals
PO Box 3200
Winnipeg MB R3C 5R7

Toll free fax: 1-877-949-4885

Questions?

Call us toll free at 1-866-367-8506
Monday to Friday, 8:00 am to 5:00 pm (CDT)

Privacy and Consent Clause

Agriculture and Agri-Food Canada (AAFC) is committed to protecting the privacy of your information. The information on this form, including your Participant Identification Number (PIN) is collected under the authority of Section 4 of the Farm Income Protection Act (FIPA) and will be used by the Administration and Appeal Committee members (including producer representatives and representatives from provincial or territorial governments) exclusively for the purposes of reviewing your appeal request and determining your eligibility for benefits. Your personal information will not be used for any other purpose except as required by law.

You have the right to request access to your personal information held by AAFC and to request changes to incorrect personal information. For more information about your rights under the Privacy Act, contact the AAFC Access to Information Privacy Coordinator at aafc.atip-aiprp.aac@canada.ca and reference AAFC PPU 183.

In addition, by submitting this form for benefits under the AgriStability and AgriInvest programs, you:

certify that the information provided is complete and correct
understand and agree that the person you identified on this form as your representative may receive information relating to your appeal from the Administration and may instruct the Administration to modify information relating to your appeal
understand and certify that where you have provided information about other individuals or entities you have been authorized by those individuals or entities to provide that information
understand and agree that where you have provided information about other individuals or entities, if they request to see the information you have submitted about them, the Administration will give them access to that information
understand that it is a criminal offense to make a false statement in application for program benefits and any declarations made are subject to audit