Personal Information Appeal Form
Note: An appeal must be sent in writing to the Federal Privacy Commissioner within six (6) months after the brokerage has given notice of its decision.
Your Information
Mr. Mrs. Ms. Miss
Surname: __________________
Given Name: __________________ Initials: __________________
Name Of Company, Association Or Organization: __________________
Address: __________________
City, Province: __________________
Postal Code: __________________
Telephone: ( )__________________
Fax: ( )__________________
Email Address: __________________
If this appeal is not being made in a personal capacity, please provide the NAME OF CONTACT, TITLE and TELEPHONE of Representative.
Representative Information (Complete only if you will be represented.)
I authorize the following person to act on my behalf and to receive any personal information pertaining to me, as necessary for the purposes of this appeal.
Representative is Lawyer Agent
Mr. Mrs. Ms. Miss
Surname: __________________
Given Name: __________________ Initials: __________________
Name Of Company, Association Or Organization: __________________
Address: __________________
City, Province: __________________
Postal Code: __________________
Telephone: ( ) __________________
Fax: ( ) __________________
Email Address: __________________
Brokerage information
Name of brokerage: __________________
Address: __________________
City, Province: __________________
Telephone number: ( )__________________
Name of privacy officer: __________________
Attachments
The following documents have been attached (if available):
Copy of the request.
Copy of the brokerage's decision letter.
Details of the Appeal
Please select the box(es) that explains why the appeal is being made.
Deemed Refusal - It is more than 30 days since I made my request and I have not received a decision.
Failure to Disclose Records - The institution decided to grant access to requested records but I have not received them.
Time Extension - The institution decided to extend the time limit for responding to my request, and I disagree.
No Jurisdiction - The institution indicated that the requested records are excluded from the Act and I disagree.
Reasonable Search - The institution indicated that some or all of the requested records do not exist and I believe that more records do exist.
Frivolous or Vexatious - The institution indicated my request is frivolous or vexatious and I disagree.
Exemptions - The institution has exempted all or part of the requested records and I believe that more of them should be disclosed.
Interim Decision - Because of the number of records at issue, the brokerage reviewed a sample of the records or consulted an experienced employee, and advised me of the exemptions that might apply, and provided me with a fee estimate. I disagree with the amount of the fee estimate.
Fee/Fee Estimate - The brokerage sent me an access decision that included a fee or fee estimate that I feel is excessive.
Fee Waiver - The brokerage has refused to grant my request to waive the fees.
Refusal to Confirm or Deny - The brokerage has refused to confirm or deny the existence of the requested records.
Correction - The brokerage has refused to make corrections to my personal information.
Other - please explain:
Resolution of Appeal
Please describe how you feel this appeal could be resolved.
Information about the Appeal Process
For more information about the processes of the Information and Federal Privacy Commissioner/ and Code of Procedure for appeals, please contact the office of the Federal Privacy Commissioner at:
Federal Privacy Commissioner
112 Kent Street
Ottawa, Ontario
K1A 1H3
Tel: (613) 995-8210
Toll free: (800) 282-1376
Where to Send this Form
This form and any additional documentation must be sent in writing to the Federal Privacy Commissioner no later then six months after the brokerage has given notice of its decision.