Collection of this information is for the purpose of conducting a proceeding before this board. It is collected/used for this purpose under the authority of subsection 20.2 of the Substitute Decisions Act. For information about collection practices, contact the office of the Regional Vice-Chair of the Board or call toll free at 1 800 461-2036.
Send this form by fax to the Office of the Regional Vice-Chair of the Board or call toll free at 1 800 461-2036 for assistance.
3234–04 (2022/11)*