Third Party Release Form

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					                                                                             Mail or fax release form to:
 Third Party Release Form                                                    CAIS Program                        Toll Free 1.877.838.5144
                                                                             Agricorp                            Fax 519.826.4334
                                                                             1 Stone Road West, 4th, NW          contact@agricorp.com
                                                                             Guelph, ON N1G 4Y2                  www.agricorp.com


By signing this release, the participant authorizes the following third party contact(s) to communicate with the Canadian
Agricultural Income Stabilization (CAIS) program regarding the participant's CAIS program file on his/her behalf. The participant
also hereby authorizes the CAIS program to disclose and discuss his/her CAIS program file with the following designated third
party contact(s). The information shared and communicated by the CAIS program to the individuals identified below may include
all personal and confidential information that may be on file with the CAIS program, Ontario Farm Income Disaster Program
(OFIDP), or received by the CAIS program by the Net Income Stabilization Account (NISA) and/or federal and provincial
departments and ministries. The participant also recognizes that the contacts listed below are not the primary contacts for this
application. Although the CAIS program will accept inquiries from the authorized contact, all correspondence will continue to be
made to the participant. This third party consent is valid for the length of time the participant participates in the CAIS program. It
is the participant's responsibility to advise the CAIS program if there is a change in the agent or third party authorized contact.
     Participant details: CORPORATION (if applicable)
Corporation Name                                                             Business Number (B.N.)              CAIS/NISA PIN Number


Name of Shareholder/Appointed Officer                                                                            Telephone Number
                                                                                                                 (   )
Signature                                                                                                        Date


      INDIVIDUAL
Name of Individual                                                           Social Insurance Number             CAIS/NISA PIN Number


Signature                                                                                                        Date


Authorized Contacts (Agent or Third Party) Details
1. Name First, Last                                          Firm or Relationship to Participant                 Telephone Number
                                                                                                                 (    ) 
  Mailing Address                                                                                                Fax Number
  R.R. / P.O. Box / Number / Street

                                                                                                                 (    )
  Town / City                                                Province                     Postal Code            Email Address

2. Name First, Last                                          Firm or Relationship to Participant                 Telephone Number
                                                                                                                 (    )
  Mailing Address                                                                                                Fax Number
  R.R. / P.O. Box / Number / Street

                                                                                                                 (    )
  Town / City                                                Province                     Postal Code            Email Address

Questions about this Third Party Release should be directed to:              Personal information on this release is collected under the authority of
Administrator, Canadian Agricultural Income Stabilization Program            the Federal-Provincial Agreement establishing the Canadian Agricultural
Agricorp                                                                     Stabilization (CAIS) Program . The information you provide will be used
1 Stone Road West, 4th Floor NW, Guelph ON N1G 4Y2                           for administration and related audit of the CAIS program. Direct
Phone: 1-877-838-5144 Fax: (519) 826-4334                                    questions about the collection of information to: Administrator,
                                                                             Canadian Agricultural Income Stabilization Program, Agricorp, 4th Floor
                                                                             NW, Guelph ON N1G 4Y2, 1-877-838-5144 Fax (519) 826-4334.

				
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