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Application for Mediation

You can use either the Web version below or the PDF (2,100 KB).

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 12th 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.

Farm Type













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 Email address 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 number Email address Estimated balance owing
Ext.
Ext.
Ext.
Ext.
Ext.
Summary of 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)



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