NOMINEE FORM - DECLARATION OF LIABILITY RELEASE Note: Please send this completed form to appehtite@mapleleaf.com. Make sure to include a photo of the Nominee along with your submission. In consideration of good and valuable consideration, the receipt and adequacy of which are hereby acknowledged, I agree with the following: I am submitting this declaration to Maple Leaf Foods Inc. with the understanding that it will be relied upon to determine whether I am eligible to receive the prize for which my entry has been selected in Maple Leaf Foods’ Promotion. I represent that I have complied with all the Rules and Regulations of the Contest and that I have perpetrated no fraud or deception in entering or in claiming my prize. I further represent that neither I nor any member of my immediate family is an employee of Maple Leaf Foods Inc., its affiliates, subsidiaries or advertising agencies or of any entity specifically excluded in the official rules. I agree to return to Maple Leaf Foods Inc. any prize which may be awarded to me if any statement made by me in this declaration is false. By accepting and participating in the Maple Leaf Foods’s Promotion, I for myself, my personal representatives, successors, assigns, heirs, legal representatives and next of kin, represent and agree to release and hold harmless Maple Leaf Foods, its affiliated and related companies and advertising, promotion agencies including the independent judging organization and all of their respective directors, officers, shareholders, employees, agents, successors and assigns (collectively, the “Contest Entities”) from any and all liability for any injuries, loss or damage of any kind arising out of or in any way related to, directly or indirectly, to the Prize. I do hereby give Maple Leaf Foods Inc. and its agents and assignees, full permission and authority to use, publish and display my name, quotes, voice and photograph or other likeness for advertising or other related purposes in any media whatsoever without additional compensation. I further acknowledge that none of the Releasees has offered any warranty or guarantee whatsoever respecting the Prize, that Maple Leaf Foods Inc. and that any claims relating to the Prize shall be exclusively addressed to the manufacturer, supplier or originator, as the case may be, of the Prize. Promotion name: Feeding the Country Grant Please fill out the information below First Name: City: Last Name: Province: Address: Postal Code: Address 2 (optional): Phone number: I am a resident in the Province selected above and I have reached the age of majority as decreed by law in such Province. By signing this document, I agree to the terms and conditions outlined in this document. In providing personal information, I acknowledge that my information will be stored on computer systems operated by a data warehouse at a site located in the United States and by providing my personal information I consent to such practice. Signature Date (mm/dd/yyyy)