Criminal Code (R.S.C., 1985, c. C-46)

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).

• □ I would like to receive information respecting any hearings held to make or review a disposition in respect of the accused.

• □ I would like to receive information respecting any disposition made in respect of the accused.

• □ If the accused is discharged absolutely or conditionally, I would like to receive notice of that discharge and of the accused’s intended place of residence.

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

Dated this day of 20, at .

Signature of declarant