Criminal Code (R.S.C., 1985, c. C-46)

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