Marginal note:Notice of orders of restitution

741.1 If a court makes an order of restitution under section 738 or 739, it shall cause notice of the content of the order, or a copy of the order, to be given to the person to whom the restitution is ordered to be paid, and if it is to be paid to a public authority designated by regulations made under subsection 739.4(2), to the public authority and the person to whom the public authority is to remit amounts received under the order.

• (a) cause a copy of the order to be given to the offender and, on request, to the victim;

Canada,

Province of ,

(territorial division).

To the court that is sentencing (name the offender) who was convicted, or was discharged under section 730 of the Criminal Code, of an offence under that Act.

I, (name of declarant), declare that (check the appropriate box):

• [ ] (i) 

  I am not seeking restitution for the losses and damages I suffered as the result of the commission of the offence.
• [ ] (ii) 

  I am seeking restitution in the amount of $ for the following losses and damages I suffered as the result of the commission of the offence.

I declare that I have suffered the following losses and damages as the result of the commission of the offence:

(Complete the following table if seeking restitution.)

I understand that the amount of my losses and damages must be readily ascertainable by the court. For that purpose, I am responsible for providing the court with all necessary documents, including bills, receipts and estimates, in support of my claim for restitution.

Dated this day of 20, at .

Signature of declarant

This form may be used to provide a description of the physical or emotional harm, property damage or economic loss suffered by you as the result of the commission of an offence, as well as a description of the impact of the offence on you. You may attach additional pages if you need more space.

Your statement must not include

• • any statement about the offence or the offender that is not relevant to the harm or loss you suffered;

• • any unproven allegations;

• • any comments about any offence for which the offender was not convicted;

• • any complaint about any individual, other than the offender, who was involved in the investigation or prosecution of the offence; or

• • except with the court’s approval, an opinion or recommendation about the sentence.

You may present a detailed account of the impact the offence has had on your life. The following sections are examples of information you may wish to include in your statement. You are not required to include all of this information.

Emotional impact

Describe how the offence has affected you emotionally. For example, think of

• • your lifestyle and activities;

• • your relationships with others such as your spouse, family and friends;

• • your ability to work, attend school or study; and

• • your feelings, emotions and reactions as they relate to the offence.

Physical impact

Describe how the offence has affected you physically. For example, think of

• • ongoing physical pain, discomfort, illness, scarring, disfigurement or physical limitation;

• • hospitalization or surgery you have had because of the offence;

• • treatment, physiotherapy or medication you have been prescribed;

• • the need for any further treatment or the expectation that you will receive further treatment; and

• • any permanent or long-term disability.

Economic impact

Describe how the offence has affected you financially. For example, think of

• • the value of any property that was lost or damaged and the cost of repairs or replacement;

• • any financial loss due to missed time from work;

• • the cost of any medical expenses, therapy or counselling;

• • any costs or losses that are not covered by insurance.

Please note that this is not an application for compensation or restitution.

Fears for security

Describe any fears you have for your security or that of your family and friends. For example, think of

• • concerns with respect to contact with the offender; and

• • concerns with respect to contact between the offender and members of your family or close friends.

Drawing, poem or letter

You may use this space to draw a picture or write a poem or letter if it will help you express the impact that the offence has had on you.

•  I would like to present my statement in court.

To the best of my knowledge, the information contained in this statement is true.

Dated this day of 20, at .

Signature of declarant

If you completed this statement on behalf of the victim, please indicate the reasons why you did so and the nature of your relationship with the victim.

Dated this day of 20, at .

Signature of declarant

This form may be used to provide a description of the harm or loss suffered by a community as the result of the commission of an offence, as well as a description of the impact of the offence on the community. You may attach additional pages if you need more space.

Your statement must not include

• • any statement about the offence or the offender that is not relevant to the harm or loss suffered by the community;

• • any unproven allegations;

• • any comments about any offence for which the offender was not convicted;

• • any complaint about any individual, other than the offender, who was involved in the investigation or prosecution of the offence; or

• • except with the court’s approval, an opinion or recommendation about the sentence.

Name of community on whose behalf the statement is made:

Explain how the statement reflects this community’s views:

You may present a detailed account of the impact the offence has had on the community. The following sections are examples of information you may wish to include in your statement. You are not required to include all of this information.

Emotional impact

Describe how the offence has affected community members emotionally. For example, think of

• • community members’ lifestyles and activities;

• • community members’ relationships with others in the community and outside it;

• • community members’ ability to work, attend school or study;

• • community members’ feelings, emotions and reactions as they relate to the offence; and

• • the community’s sense of belonging to the region.

Physical impact

Describe how the offence has affected community members physically. For example, think of

• • the ability of community members to access services; and

• • changes in transportation and routes taken to and from school, work, shopping, etc.

Economic impact

Describe how the offence has affected the community financially. For example, think of

• • any reduction in the number of visitors or tourists to the region;

• • the value of any property that was lost or damaged and the cost of repairs or replacement; and

• • any costs or losses that are not covered by insurance.

Please note that this is not an application for compensation or restitution.

Fears for security

Describe any fears that community members have for their security or that of their family and friends. For example, think of concerns with respect to contact with the offender.

Drawing, poem or letter

You may use this space to draw a picture or write a poem or letter if it will help you express the impact that the offence has had on the community.

•  I would like to present this statement in court.

To the best of my knowledge, the information contained in this statement is true.

Dated this day of 20, at .

Signature of declarant

This form may be used to provide a description of the physical or emotional harm, property damage or economic loss suffered by you arising from the conduct for which the accused person was found not criminally responsible on account of mental disorder, as well as a description of the impact that the conduct has had on you. You may attach additional pages if you need more space.

Your statement must not include

• • any statement about the conduct of the accused that is not relevant to the harm or loss suffered by you;

• • any unproven allegations;

• • any comments about any conduct for which the accused was not found not criminally responsible;

• • any complaint about any individual, other than the accused, who was involved in the investigation or prosecution of the offence; or

• • except with the court’s or Review Board’s approval, an opinion or recommendation about the disposition.

The following sections are examples of information you may wish to include in your statement. You are not required to include all of this information.

Emotional impact

Describe how the accused’s conduct has affected you emotionally. For example, think of

• • your lifestyle and activities;

• • your relationships with others such as your spouse, family and friends;

• • your ability to work, attend school or study; and

• • your feelings, emotions and reactions as these relate to the conduct.

Physical impact

Describe how the accused’s conduct has affected you physically. For example, think of

• • ongoing physical pain, discomfort, illness, scarring, disfigurement or physical limitation;

• • hospitalization or surgery you have had because of the conduct of the accused;

• • treatment, physiotherapy or medication you have been prescribed;

• • the need for any further treatment or the expectation that you will receive further treatment; and

• • any permanent or long-term disability.

Economic impact

Describe how the accused’s conduct has affected you financially. For example, think of

• • the value of any property that was lost or damaged and the cost of repairs or replacement;

• • any financial loss due to missed time from work;

• • the cost of any medical expenses, therapy or counselling; and

• • any costs or losses that are not covered by insurance.

Please note that this is not an application for compensation or restitution.

Fears for security

Describe any fears you have for your security or that of your family and friends. For example, think of

• • concerns with respect to contact with the accused; and

• • concerns with respect to contact between the accused and members of your family or close friends.

    

    

    

    

Drawing, poem or letter

You may use this space to draw a picture or write a poem or letter if it will help you express the impact that the accused’s conduct has had on you.

•  I would like to read or present my statement (in court or before the Review Board).

To the best of my knowledge, the information contained in this statement is true.

Dated this day of 20, at .

Signature of declarant