Application for Mediation

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

Please mail to:

Locations

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

Agriculture and Agri-Food Canada
Farm Debt Mediation Service
301-2010 12^th Avenue
Regina SK S4P 0M3

Toll Free Number: 1-866-452-5556
Telephone: 306-780-5544
TTY: 613-773-2600
Fax: 306-780-7353

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

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

Toll Free Number: 1-866-452-5556
Telephone (Atlantic and Quebec): 418-649-8142
Telephone (Ontario): 613-773-0878
TTY: 613-773-2600
Fax (Atlantic and Ontario): 506-452-4975
Fax (Quebec): 418-648-2439

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 (AAFC) 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.

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Farm Type

Corporation

Partnership

Sole proprietorship

Legal Name

Second legal entity

Legal name of partnership or corporation

Mailing address

City/Town

Province

Postal Code

Telephone number

Extension

Fax number

Email address

Alternate phone

Principal commodity

Type of application:

Application for a Stay of Proceedings, review of financial affairs and mediation 5 (1)(a).

Application for review of financial affairs and mediation 5 (1)(b). (This does not provide you the protection of the stay of proceedings).

Eligibility requirements

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

I / we are unable to meet my /our obligations as they generally become due;

I / we have ceased paying my / our current obligations in the ordinary course of business as they generally become due;

The aggregate of my / our property is not, at a fair valuation, sufficient, or if disposed of at a fairly conducted sale under legal process would not be sufficient, to enable payment of all my / our obligations, due or accruing due;

Notice of Intent to Realize on Security

1. Has a Notice of Intent to Realize on Security been received?

If yes, identify the originator:

Name and full mailing address
including postal code and email address

Date received (YYYY-MM-DD)

Telephone number

Extension

Fax number

Estimated balance owing

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.)

Other Secured Creditors Information
Name and full mailing address including postal code	Telephone number (Ext.)	Fax number	Email address	Estimated balance owing
Secured Creditor Mailing Address 1	Secured Creditor telephone number 1 Secured Creditor Extension 1 Ext.	Secured Creditor Fax number 1	Secured Creditor Email Address 1	Secured Creditor Estimated balance owing 1
Secured Creditor Mailing Address 2	Secured Creditor telephone number 2 Secured Creditor Extension 2 Ext.	Secured Creditor Fax number 2	Secured Creditor Email Address 2	Secured Creditor Estimated balance owing 2
Secured Creditor Mailing Address 3	Secured Creditor telephone number 3 Secured Creditor Extension 3 Ext.	Secured Creditor Fax number 3	Secured Creditor Email Address 3	Secured Creditor Estimated balance owing 3
Secured Creditor Mailing Address 4	Secured Creditor telephone number 4 Secured Creditor Extension 4 Ext.	Secured Creditor Fax number 4	Secured Creditor Email Address 4	Secured Creditor Estimated balance owing 4
Secured Creditor Mailing Address 5	Secured Creditor telephone number 5 Secured Creditor Extension 5 Ext.	Secured Creditor Fax number 5	Secured Creditor Email Address 5	Secured Creditor Estimated balance owing 5

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.)

Unsecured Creditors Information
Name and full mailing address including postal code	Telephone number (Ext.)	Fax number	Email address	Estimated balance owing
Unsecured Creditor Mailing Address 1	Unsecured Creditor telephone number 1 Unsecured Creditor Extension 1 Ext.	Unsecured Creditor Fax number 1	Unsecured Creditor Email Address 1	Unsecured Creditor Estimated balance owing 1
Unsecured Creditor Mailing Address 2	Unsecured Creditor telephone number 2 Unsecured Creditor Extension 2 Ext.	Unsecured Creditor Fax number 2	Unsecured Creditor Email Address 2	Unsecured Creditor Estimated balance owing 2
Unsecured Creditor Mailing Address 3	Unsecured Creditor telephone number 3 Unsecured Creditor Extension 3 Ext.	Unsecured Creditor Fax number 3	Unsecured Creditor Email Address 3	Unsecured Creditor Estimated balance owing 3
Unsecured Creditor Mailing Address 4	Unsecured Creditor telephone number 4 Unsecured Creditor Extension 4 Ext.	Unsecured Creditor Fax number 4	Unsecured Creditor Email Address 4	Unsecured Creditor Estimated balance owing 4
Unsecured Creditor Mailing Address 5	Unsecured Creditor telephone number 5 Unsecured Creditor Extension 5 Ext.	Unsecured Creditor Fax number 5	Unsecured Creditor Email Address 5	Unsecured Creditor Estimated balance owing 5

Summary of assets

Summary of assets
Cash	$ Cash
Marketable securities	Marketable securities
Accounts receivables	Accounts receivables
Livestock – type and quantity	Livestock – total quantity
Livestock – type	Livestock – quantity
Livestock – type	Livestock – quantity
Livestock – type	Livestock – quantity
Livestock – type	Livestock – quantity
Livestock – type	Livestock – quantity
Livestock – type	Livestock – quantity
Grain, produce, forage – type and quantity	Grain, produce, forage – total quantity
Grain, produce, forage – type	Grain, produce, forage – quantity
Grain, produce, forage – type	Grain, produce, forage – quantity
Grain, produce, forage – type	Grain, produce, forage – quantity
Grain, produce, forage – type	Grain, produce, forage – quantity
Grain, produce, forage – type	Grain, produce, forage – quantity
Farm supplies	Farm supplies
Quota	Quota
Land, buildings and improvements – legal description	Land, buildings and improvements – total value
Land, buildings and improvements – legal description	Land, buildings and improvements – value
Land, buildings and improvements – legal description	Land, buildings and improvements – value
Land, buildings and improvements – legal description	Land, buildings and improvements – value
Land, buildings and improvements – legal description	Land, buildings and improvements – value
Machinery and equipment – description	Machinery and equipment – total value
Machinery and equipment – description	Machinery and equipment – value
Machinery and equipment – description	Machinery and equipment – value
Machinery and equipment – description	Machinery and equipment – value
Machinery and equipment – description	Machinery and equipment – value
Machinery and equipment – description	Machinery and equipment – value
Machinery and equipment – description	Machinery and equipment – value
Machinery and equipment – description	Machinery and equipment – value
Machinery and equipment – description	Machinery and equipment – value
Machinery and equipment – description	Machinery and equipment – value
Machinery and equipment – description	Machinery and equipment – value
Machinery and equipment – description	Machinery and equipment – value
Machinery and equipment – description	Machinery and equipment – value
Other assets – description	Other assets – total value
Other assets – description	Other assets – value
Other assets – description	Other assets – value

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

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

Farm location

in the province of
have access to any and all records, books, papers, and other documentation concerning my/our financial affairs (including all security documents); and
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.

In addition to being notified by Agriculture and Agri-Food Canada, its employees, agents and contractors by telephone, mail or courier, I/we agree to be informed or notified, where required by the Act or the Regulations, by facsimile or electronic mail as indicated below:

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

Dated this Todays date day of Todays month (year) current year at current location.

(Where farmer is a person or partnership)

Farmer signature (by hand only)

(Where farmer is a company or cooperative)

Officer signature (by hand only)

Corporate seal

Officer signature (by hand only)

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Application for Mediation

Locations

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

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