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 firstname.lastname@example.org 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.