Government of Ontario: Consent and Capacity Board

Notice of Withdrawal



regarding (please check):









(signature of applicant's lawyer/agent or applicant[if unrepresented])*





(telephone no.) -  

*   If the applicant is a patient in a psychiatric facility and does not have legal representation, this section must be completed:

and (select one):


(signature of witness)





(telephone no.) -  

For your information:

Application forms are treated independently:  You must check every applicable box if you intend to withdraw more than one application.

Withdrawal of Forms B, C, D, E, F, or G:  If one of these applications is withdrawn, the law will no longer provide that the patient is deemed to have applied for a review of his or her capacity to make the relevant decision. If the subject of the application still wants the Board to review a finding of incapacity, he or she must bring an application under a Form A.

4323-04(04/07)
www.ccboard.on.ca
(Disponible en version franšaise)