Request Mediation

Permission to Release Personal and Financial Information to the Agricultural Mediation Program. If you would prefer to print the form and mail it to us; click here.

I hereby give permission to lenders, governmental agencies, and any other entities to release personal, financial, and other information to the Agricultural Mediation Program. I further give permission to those persons or entities to discuss all such matters with the Agricultural Mediation Program in order to resolve any issues.

I hereby give permission to the Agricultural Mediation Program to release any information provided to the Agricultural Mediation Program or the mediator assigned to the case. I understand this information is being released for the purpose of mediation only and shall not be released for any other purpose without my permission.

My signature on this form is valid in any format, whether printed, copied, or sent electronically. If submitted electronically, the box below is valid as my signature for purposes of this document.