Government of Ontario: Ministry of Transportation

I/We the undersigned, being the owner or owners of land in territory without Municipal organization in District of , Province of Ontario, hereby appoint of the of as my/our agent for the purpose of making an arrangement with the Minister of Transportation under The Public Transportation and Highway Improvement Act, for the improvement, maintenance or repair of the road situated in the said territory and described as follows:

And I/We hereby authorize him to pay to or receive from the Ministry of Transportation on my/our behalf any monies which may be required by such arrangement.