Request Mediation

Request Mediation Form

Please complete the form below to request mediation from the Agricultural Mediation Program. If you would rather print the form and mail it to us; click here. Once your request has been received we will review your information and contact you.

NEW Request Mediation Form (all programs)

List people and/or USDA agency you are requesting mediation with

List additional participants in the mediation

Release Information Form

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.

Sending
Contact

Matt Strassberg
Director

EMC/Ag Mediation
177 Paddy Hill Road
Moretown, VT 05660
(802) 583-1100