Criminal Code

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 referred to in subsection 380(1) of that Act.

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

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

• [ ] (ii) I am seeking restitution in the amount of $ for the following losses I suffered as a result of the commission of the offence.

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

(Complete the following table if seeking restitution.)

Description (describe each thing of which the declarant was defrauded)	Amount of loss (state, in respect of each thing, the amount of the loss)
1.
2.
3.
4.

I understand that the amount of my losses 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