Criminal Code (R.S.C., 1985, c. C-46)

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