92
Parole Board
of Canada
Commission des libérations
condit ionnelles du Canada
a
PRO TE CTED
B
ONCE COMPLETED
Correctional Service
Canada
Service c orr ect ionnel
Canada
NOTE: Reference documents – CD 784
, CCRA
and
PB C Policy Manu al
GUIDE FO R APPLICATION T O RECEIVE INFO RM ATION
AS A VICTIM
PUT AWAY ON FILE
Origin al =
Plea se refer to pa ge 1 o f th e
Appl ica tion
The Corrections and Conditional Release Act ( CCRA) allo ws th e Co rre ctio na l Ser vice o f Can ada ( CSC) a nd the Pa ro le
Boar d of Ca na da ( PBC) to gi ve victim s of cr ime infor mation a bo ut the offend er who h ar med the m du ring the offend er ’s
senten ce . T he pr ocess o f p rovidin g this in form atio n is ca lle d ‘victim no tification’.
This Guid e co nta in s:
1. Inform ation a bou t a ppl ying to r eceive victim no tification ( Qu estio ns a nd a nswe rs an d Anne x A) (CSC
(CSC
C
, PBC
C
)
2. Th e app lica tio n for r equ esting info rma tio n (Fo rm CSC/SCC 1429E
429E
or For m PBC/CLCC 0031E
E
)
3. Instr uctio ns fo r comp letin g the Ap plication to Receive Infor mation a s a Victim fo rm (CSC
, PBC
)
INFO RM ATION ABOUT APPLYING T O RECEIVE VICT IM NOTIFICATION
Wh at is the r ole of th e CSC and PBC?
The Cor re ction al Ser vice o f Cana da ( CSC) is th e fe der al g overn me nt a gen cy re sp on sib le un de r th e Corrections and
Co nd itio nal Rele ase Act (CCRA)
for a dm in ister ing sen tences of indi vidu als wh o re ce ive d a term o f two ye ar s or m or e,
as im po se d by the co ur t. CSC is re sp onsib le fo r ma nag ing in stitution s of va rio us se cu rity leve ls an d su pe rvisin g
offen der s un de r co nd itio na l r elea se in th e commu nity.
The Pa ro le Boar d of Ca na da ( PBC) is a n ind ep en den t a dmin istra tive trib una l th at has th e au thor ity un der th e
Co rr ectio ns and Con dition al Relea se Act ( CCRA)
to gr ant or d en y cer ta in typ es o f tem por ar y ab se nces, a s well as
gr ant, den y, or r evoke d ay p aro le an d full par ole fo r ind ivid uals wh o re ce ive d a sen te nce of two yea rs o r mo re. The
Boar d also ha s the a uth ority to imp ose special con ditions du ring a n offen der ’s statutor y r elea se a nd lo ng ter m
supe rvisio n or der s.
Wh o c an app ly t o rec eive inf ormat ion f rom CSC a nd PBC?
You can a pp ly if you a re 1 8 year s o ld or o lder and are a per son who :
•
ha s suffere d ha rm an d/or p hysica l o r em otiona l d ama ge as a re su lt o f an offence for which the o ffe nde r ha s b een
convicte d;
•
is a spo use, fa mily me mbe r or g uar dia n of th e per son who h as be en ha rm ed an d is n ow d ecea se d, incapa cita te d
or u nd era ge ( und er 1 8 year s old) ;
•
is a comm on- law p ar tn er o f the p er so n who was h ar med a nd is now dece ased o r incap acita te d an d who was li ving
with the p er so n at th e time of th e pe rson's dea th fo r a pe rio d of at le ast o ne yea r;
•
is a g uar dia n of th e de pen da nt(s) of a pe rson who has be en ha rm ed an d is n ow d ecea se d, incapa cita te d or
und er ag e (u nde r 18 ye ars old) ;
•
wa s ha rm ed as a re su lt o f an o ffe nce for which the o ffe nde r was n ot co nvicte d, if a comp laint abo ut th e act wa s
mad e to police a nd/or th e Crown.
Wh en shou ld I a pply?
You can a pp ly at an y tim e wh ile the offen der is ser vin g a fede ra l sen tence (a se nten ce o f two ye ar s or mor e). (See
be low for in form ation ab ou t o ffe nde rs se rving sen te nces of le ss th an two ye ar s.)
Do I hav e to app ly t o rec eiv e vict im not if ic at ion ?
Yes, you m ust subm it a re qu est. Victim no tification is onl y pr ovided to a n ind ivid ua l who sub mits an app lica tio n for m
an d mee ts th e leg al de fin itio n or crite ria of victim. If yo u wish to pr esen t a stateme nt a t a Pa role Bo ar d he ar in g an d/or
to obtain fu nd in g to ob se rve a Par ole Boa rd hea rin g yo u must com plete d iffe ren t for ms for th ose pur po se s.
You d o not ha ve to b e re giste re d to:
•
pr ovide info rma tio n to CSC and /or PBC for co nsid er ation in decisions;
•
ob se rve a pa ro le he arin g;
•
ob ta in a wr itte n su mma ry o f PBC d ecisio ns r eg ar ding th e offend er thr ou gh PBC’s Decisio n Re gistry; o r
•
re ce ive in form ation ab ou t a n offend er’s jud icia l r eview und er section 7 45 .6 (2.8 ) of th e Criminal Code
.
PBC/CLCC 0031E (R-201 4-11) (Word Ver sio n & PDF) P age 1 of 11
of 11
Also a vai lable at CSC/SCC 1429E
Voir le fo rmu laire PBC/CL CC 0031F ou CS C/SCC 1 429F po ur la version française
38
Do I hav e to app ly sepa ra tely t o CSC a nd PBC?
No , you o nly nee d to co mple te o ne a pp lica tio n. Bo th CSC and PBC ha ve ju risdiction o ve r fede ra l o ffe nde rs. So , when
when
yo u comp lete th e Application to Receive Information as a Victim form
and r eceive confirm ation of your reg istr ation fr om
on e age ncy, you will b e con sid ere d for r egistra tio n with the othe r ag ency a s well.
Wh at info rmation ca n I re ceiv e once I am reg is te red?
The CCRA ou tlin es th e typ es o f in fo rma tio n that ca n be p ro vid ed to victims. So me infor mation can be pr ovide d b y both
ag encies, so me by o nl y on e. Se e Annex A
A
for fur ther deta il.
Ho w will I be n otified ?
No tification m ay b e pr ovide d by p ho ne or mail, d ep en ding on you r cir cumstances and pre fer ences. If yo u wish, yo u
yo u
ma y be n otifie d thro ug h a third p ar ty such as a fa mily m embe r or victim ser vices wo rker .
Wh at if th e off ende r is s erv ing a sent enc e of les s th an tw o yea rs?
If the offen de r is incar cera ted ( in priso n), yo u ma y be able to re ceive infor ma tion fr om Victim Ser vices in th e p rovince
wh er e th e offen der is serving h is/h er sen te nce. You can o btain con tact info rma tio n fr om Pub lic Safety Ca nad a’s
Na tio na l O ffice for Victim s by ca lling toll- fr ee to 1 -86 6- 525 -0 55 4 or visit http://www.csc-scc.gc.ca/victims-victimes/sbp-
spp- eng .sh tm l
and click on ‘Pr ovincial Partn ers – Ser vices by p ro vin ce ’.
If the offen de r is on co nditio nal re lea se ( ha s ap plie d for/h as b ee n gr anted p ar ole ), you ca n ob ta in contact infor mation
from Pu blic Safe ty Ca nad a’s Na tio na l O ffice for Victims by ca llin g toll- fr ee to 1- 86 6- 525 -0 55 4 or visit http://www.csc-
scc.gc.ca/victims-victim es/sbp -spp- en g.shtml
and click on ‘ Pr ovincial Par tn er s – Se rvice s b y pr ovince’.
Ho w ca n I apply t o r ece iv e v ic tim n otifica tion fro m CSC and PBC?
Co mple te th e Application to Receive Information as a Victim form
of this Guide
. Sig n th e form and m ail o r fax it to th e
CSC o r PBC o ffice yo u ha ve bee n in con ta ct with ( se e address and fax information
). If you ha ve n ot yet be en in
contact with a pa rticular o ffice, send it to th e office n ea re st you .
If yo u ha ve que stio ns a bo ut co mple ting th is for m, p lease see the Instructions
. Fo r an y r ema ining q ue stion s, you can
contact CSC Victim Se rvice s toll fre e at 1 -8 66- 80 6- 227 5 or PBC’s toll- free victim in fo lin e at 1- 866 -7 89- 46 36.
PBC/CLCC 0031E (R-201 4-11) (Word Ver sio n & PDF) P age 2 of 11
2 of 11
1
95
Anne x A – Inf ormat ion t hat CSC a nd PBC Ca n Disc los e to Regis ter ed Victims
When victims wh o me et the d efinition o r criter ia in the Corrections and Conditional Release Act (CCRA) (Section 26
,
Sectio n 14 2
) r eq uest in form ation, CSC and PBC must
disclose:
•
th e offen der ’s n ame ,
•
th e offen ce fo r wh ich th e offend er was co nvicte d an d th e cour t tha t con victed the offend er,
•
th e offen der ’s sen te nce sta rt da te a nd le ngth , an d
•
th e offen der ’s e ligibility d ates and r eview date s ( fo r temp ora ry a bsen ce s a nd p aro le) .
When victims wh o me et the d efinition o r criter ia in the Corrections and Conditional Release Act (CCRA) r eq uest
infor mation , CSC an d/or PBC may
disclose:
CSC
PBC
•
th e offen der ’s a ge
•
th e na me of the pe niten tia ry wh ere th e offend er is incar ce ra te d
•
th e location of th e pen itentia ry whe re the o ffe nd er is in carce rated
•
wh ethe r the offen de r is in custod y an d, if no t, the re ason wh y the offen de r is n ot
t
in cu sto dy
•
infor mation o n tr an sfe rs: a dvance n otice o f tra nsfer to a min imum- secur ity
institu tio n and re asons for all tra nsfe rs
•
th e pr og ram s in which the offen de r is pa rticip ating o r ha s p articipa te d
•
th e serio us discip linar y o ffe nces tha t the offend er ha s com mitted
•
re lease con ditions (for te mpo rar y a bsence s, wo rk re le ase, par ole or sta tu tor y
re lease) and r ea so ns fo r temp or ar y absen ces
•
re lease da tes ( for tem por ar y ab se nces, wor k r elea se , p ar ole or statuto ry
re lease)
•
th e offen der ’s d estin ation u po n re lease
•
th e da te of h ea ring s for revie w of se ction 130 o f the CCRA (d eten tio n)
•
wh ethe r or n ot th e offen der has ap pea led a d ecisio n of the PBC u nde r sectio n
14 7 of th e CCRA a nd the o utcome o f the a pp eal
•
th e da te s, de stin ation a nd r eason s for tr avel per mits
•
wh ethe r th e offen de r’s con dition al re le ase ha s b ee n su sp en ded
•
Lo ng- term sup er vision o rde rs (L TSO)
•
th e en d da te of a L on g- te rm sup ervision or de r
•
th e na me of the pr ovince to which the offen de r has be en tra nsfer red a nd
confirm ation that the o ffe nde r is in a p ro vin cia l cor re ctio nal facility
•
wh en a n eligi ble offen der did n ot a pp ly for ju dicial re vie w (r ed uctio n of par ole
ine lig ibility p erio d) a nd the next d ate o n wh ich th e offend er can r ea pp ly
•
th e re ason fo r a wa ive r of the r ig ht to a hea rin g un der su bsection 14 0( 1) , if the
offen der g ive s on e.
PBC/CLCC 0031E (R-201 4-11) (Word Ver sio n & PDF) P age 3 of 11
1
THIS PAGE IS I NT ENT IONAL LY LEFT BL ANK
85
Parole Board
of Canada
Commission des libérations
condit ionnelles du Canada
a
PRO TECTED
B
ONCE COMPLETED
Correctional Service
Canada
Service c orr ect ionnel
Canada
NOTE: Reference documents – CD 784
, CCRA
and
PB C Policy Man ual
APPLICATIO N TO RECEIVE INFORMATION AS A VICTIM
PUT AWAY ON FILE
Origi nal =
PBC Case fil e
CS C Victi m file
Instru cti ons
Pl ease ensure Parts A to C are completed
Under the Corrections and Conditional Release Act (CCRA), the Correcti onal Serv ic e of Canada (CSC) and the Parol e B oard of Canada (PBC) may
provide people who appl y to receive i nformation as a v icti m wi th information about the offender who harmed them. Pl eas e complete this appl icati on
form if you wis h to receiv e informati on as a vic tim.
A gui de to as sis t in the completi ng of this applic ation is av ai labl e on the CSC and PB C webs ites . To find out more about who is c ons idered a v ictim
under the Ac t, consul t the CSC or PB C websi tes , at www.csc-scc.gc.ca/victims-victimes
or www.pbc-clcc.gc.ca
.
If y ou would l ike to provide additi onal informati on that i s not rel ated to the applic ation, please dis cuss how to do this wi th CSC or P BC s taff. You wil l
fi nd c ontact informati on at the end of this f orm.
Vi cti m In fo rmation and Details
Name
(prin t)
Date of birt h
(YY YY-MM-DD)
NOTE: You must be 18 years of age or older to apply to receive information about an offender. If you were harmed by an offender and you are under
18, a parent or guardian may apply to rec ei ve information about the offender on your behalf.
Name of the offender
(p rin t)
who harmed you? Pl eas e identify i f there was more than one offender inv ol ved.
Was the offender convic ted of the ac t that harm ed y ou?
Yes
No
Did y ou provi de a v icti m impact statement for c ourt?
Yes
No
PART A – Request to recei ve i nfo rmati on as a vi ctim
Pl ease check the O NE statement that best suits your situati on:
(1)
I was harmed (s uff ered a loss or have been physi cal ly or emoti onal ly hurt) as a resul t of a c rimi nal offenc e.
Please go to A1
(2)
I am the s pous e, common-l aw partner or relativ e of, or legall y responsibl e for, the pers on who was harmed as a res ult of a crimi nal
al
offence and that person is now deceased, ill, incapacitated or under the age of 18, or I am the guardian of the dependents of that
pers on.
Please go to A2
(3)
I was harmed as a res ult of an act committed by an offender (whether or not the offender was prosec uted or convi cted of that ac t)
and a c omplaint was made to t he poli ce or the Crown attorney , or an informati on was laid under the Criminal Code, in res pect to that
act.
Please go to A3
PRIVACY NOTI CE STAT EMENT
The informati on you provi de on thi s form i s coll ected by CSC/PBC under the aut hority of the Corrections and Conditional Release Act (CCRA) f or the
purpos e of determini ng y our eli gibil ity to receiv e informati on about an offender who harmed you. Miss ing pers onal informati on may resul t in your
reques t being denied. You have the ri ght to the correc tion of, acces s to, and protecti on of y our pers onal informati on under the Privacy Act. Personal
information c ol lected through the proc essi ng of your appli cation wil l be stored i n the Personal I nf ormation Bank CSC PPU 135 and PBC PPU 015
and c an be acc essed and ass es sed for ac curac y by s endi ng a wri tten request to the Direc tor, Ac cess to Informati on and P ri vacy , at ei ther
Correcti onal Serv ice of Canada (340 Laurier Avenue West, O ttawa ON, K1A 0P9) or Parole Board of Canada (410 Laurier Ave W es t, Ottawa, O N
K1A 0R1).
Pl ease note that your personal contact information, such as your telephone number and address, will not
be shared with the offender
without your consent. For more information visit Info Source www.infosource.gc.ca
.
PBC/CLCC 003 1E (R- 2014-1 1) (W ord Version & P DF) Pag e 4 of 11
4 of 11
1
Also availab le a t CSC/SCC 1429E
Voir le formulair e PB C/CLCC 00 31F ou CSC/S CC 1429 F pour la versi on fra nça ise
58
Pl ease fill o ne sectio n on ly (A1 or A2 or A3)
A1: I was harmed (suffered a lo ss o r have b een ph ysi cal ly or emotio nall y h urt) as a resul t of a crimin al offence.
.
Offenc e(s ):
Pl ease tell us about your connection to the offence. Check ONE of the follow ing:
A.
The offence was commi tted agains t m e.
B.
The offence was commi tted agains t someone with whom I have a clos e and di rec t relati ons hip.
Name of the pers on:
My rel ationshi p to the person is:
C.
I have a connecti on to the offence (Desc ri be how you are c onnected):
In what provi nce and city was the offender prosec uted? Pl eas e tell us the name of the court i f you know it.
Provi nce:
City:
Court:
Pl ease go to P ART B
OR
A2: I am th e spouse, common-l aw partner, rel ative of, o r legall y resp onsi ble fo r the person wh o w as h armed and who is
now deceased, i ll , in capacitated, or un der the age of 18, o r am the gu ardi an of the depend en ts of th at person .
Pl ease tell us about the person who was harmed as the result of the offence (who is now deceas ed, i ll, i ncapacitated or under the age of 18):
Full Name
Date of Birth
(Y YYY-MM-DD)
My r elationshi p to them
Are y ou the s pous e, common-law partner, rel ative or
guardian of the pers on harmed, or guardi an of the
dependants of the person harmed?
Offenc e(s ):
In what provi nce and city was the offender prosec uted? Pl eas e tell us the name of the court if you know it.
Provi nce:
City:
Court:
Pl ease go to P ART B
OR
A3: I was harmed as a resu lt of an act commi tted by an o ffen der (wh ether o r not the offend er w as p ro secuted o r con vi cted
of th at act) an d a compl ain t was made to the po lice or the Crow n attorney, or an info rmatio n w as l ai d u nder the
Crimin al Code, in respect to that act.
The l aw enables the CSC and PBC to provi de i nformation about an offender if you demonstrate that you meet the two c ri teria bel ow from
sec tions 26(3) and 142(3) of t he Corrections and Conditional Release Act.
Harm w as done to you, or you suffered physical or emotional damage, as a result of an act of an offender, whether or not the
offender was pr osecuted or convicted for that act,
and
A complaint was made to the police or a Crown attorney, or information was laid under the Criminal Code, in respect of that act.
I meet thes e two c riteria.
1.
What was the ac t or offence that harmed you?
2.
What is your connec ti on to the offence? (See examples i n S ection A.3.2 of the Instructions for Completing Application to Receive Information
as a Vic tim)
3.
How were you affec ted by the offence? (See examples i n Section A.3.3 of the Instructions for Completing Application to Receive Information
as a Vic tim)
Name of Polic e Offic e / Crown Offi ce where the complai nt was made about the ac t(s ):
Polic e/Crown Fil e #:
PBC/CLCC 003 1E (R- 2014-1 1) (W ord Version & P DF) Pag e 5 of 11
of 11
104
PART B – Con tact I nformati on
n
Pl ease tell us how you would like to receive information from CSC and PBC about the offender(s).
Mail ing Address (Apt., Street, P.O. B ox)
City /Town
Provinc e
Pos tal Code
Resi dent ial Address (if different than mai ling addres s)
Ci ty/Town
Emai l
Home Phone
Bus iness Phone
Cel lular Phone
Al ternate Phone
( )
( )
( )
( )
In what order should we call t he above tel ephone numbers ? Please number 1 through 4.
.
Home
Bus iness
Cellul ar
Alternate
May we leave a mes sage on y our voi ce mail ? (i .e. our name, phone number, organi zation and whether or not it i s urgent)
)
Pl ease answer Yes (Y) or No (N).
Home
Bus iness
Cellul ar
Alternate
Can CSC and PBC leav e a mess age if someone other than you answers the phone?
If y es , please provide the name(s ) and rel ationshi p(s) to you.
YES
NO
Name(s )
Relations hip(s ) to you
Noti ficati on by an Agent (opti onal)
If you would like to name a person as an agent to r eceive information about the offender on your behalf, rather than receiving it directly,
please provide the follow ing information. *NOTE: If you complete this section, CSC and P BC will not contact you directl y.
Agent’ s name or Name of Agenc y
(p rin t)
Agent’s rel ati on to you (mother, friend, lawyer, vic tim servic es, poli ce, etc.)
Mail ing Address (Apt., Street, P.O. B ox)
City /Town
Provinc e
Pos tal Code
Agent’ s Tel ephone Numbers and Emai l
l
Home
Bus iness
Facsim ile
Cellul ar
Alternate
( )
( )
( )
( )
( )
Emai l:
PART C – App licant’s Signature (You must sign this form in order for CSC or PBC to register you as a victim).
ictim).
To the best of my know ledge, I am a victim and/or a person harmed as per the definition or criteria in the Corrections and Conditional
Release Act and the information provided by me in this application is true.
►
Signature
Date
(Y YYY -MM-DD)
PART D (op tio nal) – APPLI CATIO N TO RE CEI VE INFO RMATI ON AS A VICTI M’S SPO USE/ CO MMON-LAW PARTNER
TNER
Si gnatur e of Applicant’s Spouse/Common-Law Partner (Your spouse or common-law partner must sign this form in order for CSC or PBC to
regist er him or her as a vi ctim).
To the best of my knowledge, I am also a victim and/or a person harmed as per the definition or criteria in the Corrections and Conditional
Release Act and the information provided by me in this application is true. I have checked the box below that best matches my situation:
1: I was harmed (suffered a loss or have been physically or emotionally hurt) as a result of a criminal offence.
2: I am the spouse, common-law partner, or relative of, or legally responsible for, the person who was harmed as a result of a criminal offence
and that pers on is now deceased, ill, incapacitated or under the age of 18, or I am the guardi an of the dependents of that person.
3: I am a person who was harmed as a result of an act committed by an offender (whether or not the offender was prosecuted or convicted of
of
that ac t) and
a complai nt was made to the polic e or the Crown attorney, or i nformation was l ai d under the Criminal Code, i n respec t to that
I meet these two criteri a. (refer to secti on A3 on the sec ond page)
1.
What was the act or of fenc e t hat harmed you?
2.
What i s your connection to the offenc e? (See exampl es in Part D of the Instructions for Completing Application to Receive
Informat ion as a Vic tim)
3.
How were you affected by the offenc e? (S ee exampl es in Part D of the Instructions for Completing Application to Receive
iv e
Informat ion as a Vic tim)
►
Name
(print)
Signature
Date of Birth
(YY YY-MM-DD)
DD)
Date of Si gnature
(Y YYY -MM-DD)
DD)
PBC/CLCC 00 31E (R-2014- 11) (Word Version & PDF) Pa ge 6 of 11
6 of 11
1
103
Once you have completed and si gned the form, please send it to the office that you have been in contact w ith. If you have not been in
n
contact w ith a PBC or CS C office, please send the completed form to the office nearest you. See list below.
For more information or to obtain an addi tional form, please go to CSC: www.csc-scc.gc.ca/victims-victimes
times
or PBC: www.pbc-clcc.gc.ca
.
If you need assistance, please call any of the toll-free numbers listed below .
PAROLE BOARD CANADA
CO RRECTIO NAL S ERV ICE CANADA
Address
Victims’ Information Lines
Addr ess
Victims’ Infor mation Lines
PBC – Atlantic Region
CSC – Atlantic Region
(New Bru nswick, Nova Sco tia, Prince Edwa rd Isla nd, Newfou nd lan d a nd La brad or)
1045 Main Street, Unit 101
Moncton, New Br unswick
E1C 1H1
Toll -Free: 1-866-789-INFO (4636)
Fax #: 506-851-6926
1045 Main Street, 2
nd
Fl oor
Moncton, New Brunswick
E1C 1H1
Toll- Free: 1- 866- 806-2275-1-5
Fax #: 506-851-4684
PBC – Q uébec Region
CSC – Québec Region
200 René Lévesque Blvd West
10th Fl oor, Suite 1001
Montr éal, Québec
H2Z 1X4
Toll -Free: 1-877-333-4473
Fax #: 514-283-5484
3 Place Laval, 2
nd
Floor
Laval , Québec
H7N 1A2
Toll- Free: 1- 866- 806-2275-2-4
Fax#: 450-967-3774
PBC – Ontar io/Nunavut Region
CSC – Ontario Region
(East of Thu nde r Ba y an d with in th e t errito ry of Nu na vut)
516 O'Connor Driv e
Kingston, Ontar io
K7P 1N 3
Toll -Free: 1-800-518-8817
Fax #: 613-634-3862
443 U nion Street Wes t
P.O. Box 1174
Ki ngston, Ontari o
K7L 4Y8
Toll- Free: 1- 866- 875-2225
Fax #: 613-536-4730
PBC – Prairies Region – Saskatoon Office
(S aska tche wa n, Ma nit oba , NW On tario)
CSC – Prairies Region
(Alb erta , Sa skat chewan , Man ito ba, NWT, NW On tario up to and inclu ding Thu nd er Ba y)
101-22
nd
Street E., 6
th
Floor
Saskatoon, Saskatc hewan
S7K 0E1
Toll -Free: 1-888-616-5277
Fax #: 306-975-5200
P.O. Box 9223
Saskatoon, Saskatchewan
S7K 3X5
Toll- Free: 1- 877- 322-5822
Fax #: 306-659-9314
PBC – P rairies Region – Edmonton O ffice
(A lberta a nd NWT)
Scotia Pl ace, Scoti a 2
Sui te 401, 10060 J asper Ave.
Edm onton, Alber ta
T5J 3R8
Toll -Free: 1-800-597-4397
Fax #: 780-495-4403
PBC – Pacific Region
(B ritish Columbia , Yu kon )
CSC – P acific Region
(B ritish Columbia , Yu kon )
1925 Mc Call um R oad, 2
nd
Floor
Abbotsford, British Col umbia
V2S 3N 2
Toll -Free: 1-888-999-8828
Fax #: 604-870-2498
Uni t 100 - 33991 Gl adys Avenue
P.O. Box 4500
Abbotsfor d, British C olumbia
V2S 2E8
Toll- Free: 1- 866- 806-2275-1-1
Fax #: 604-870-6152
PBC/CL CC 0031E (R-20 14-11 ) (Word V ersio n & PDF) Page 7 of 11
of 11
69
TO BE COMPLETED BY THE CO RRECTIO NAL SERVICE O F CANADA AND/O R
PARO LE BO ARD OF CANADA O NLY
Y
Applicant Name:
Offender Name:
FPS/File
Number:
1. Is the name of the vic tim different now from the name at the ti me of the offence?
Yes
No
If yes, prov ide the name at the time of the offence:
2. W as harm suffered?
Yes
No
If yes, li st the documents used to verify thi s:
3. W as t he offender c onvic ted of the act that harmed the vi ctim?
Yes
No
a. If yes, li st the documents used to verify thi s:
b.
If no, was a c ompl aint made to the Pol ice/Crown or an i nformation laid under the Criminal Code?
(Record detai ls regardi ng v eri fication of the compl ai nt made to Pol ice/Crown or the i nf ormation
)
Yes
No
Polic e / Crown Fil e #:
Name and positi on of the pers on who confi rmed the complai nt/i nformation l ai d:
Date
(YYYY -MM-DD)
4. Does this appl ic ant meet the definiti on or criteria of a vic tim?
Yes
No
Section 2.1 of the CCRA
Section 2.1(c ) of the CCRA
Section 2.1(a) of the CCRA
Section 2.1(d) of the CCRA
Section 2.1(b) of the CCRA
Section 26(3)/142(3) of the CCRA
5.
If the applic ant’s s pous e/common-law partner is also apply ing, does the spouse/common-law partner meet
the defini tion or c riteria of a vi ctim?
Yes
No
Section 2.1 of the CCRA
Section 2.1(c ) of the CCRA
Section 2.1(a) of the CCRA
Section 2.1(d) of the CCRA
Section 2.1(b) of the CCRA
Section 26(3)/142(3) of the CCRA
6. Rationale for decis ion:
7.
Name of Delegated Authori ty (CSC)
(p rin t)
Pos ition
►
Si gnature
Date
(YY YY-MM-DD)
8.
Name of Del egated Authority (PBC)
(print)
Pos ition
►
Si gnature
Date
(YY YY-MM-DD)
PBC/CL CC 0031E (R-20 14-11 ) (Word V ersio n & PDF) Page 8 of 11
8 of 11
1
73
Parole Board
of Canada
Commission des libérat ions
condit ionnelles du Canada
a
PROTECTED
B
ONCE COMPLETED
Correct ional Service
Canada
Service correctionnel
Canada
NOTE: Reference document – CD 784
, CCRA
and
PBC Policy Manual
INSTRUCTIO NS FOR COM PLET ING THE
APPLICATION T O RECEIVE INFO RM ATION AS A VICTIM F ORM
PUT AWAY O N FILE
Origin al =
Please refer to page 1 of the
Application
Vict im Infor mation an d De tails
Name a nd Da te of Birt h
Pr ovide you r curr en t le gal na me . If you ha ve ch an ged yo ur n ame since the time o f the com mission o f the o ffe nce th at
at
har med you , you n ee d to pr ovid e your pre vious na me. Yo ur d ate of bir th is re quir ed to e nsur e th at yo u ar e 18 yea rs of
age o r old er.
Name of the of fe nder (s ) who ha rmed you
If mor e th an o ne offen de r ha rme d yo u, p ro vid e the n ame s of all th e offen der s you a re r eq uesting info rm atio n ab out.
Was /wer e the of fe nder( s) conv icte d of the a ct t hat harmed y ou?
Che ck Yes o r No ba se d on you r situ ation . If you d o no t kn ow, lea ve this sp ace b la nk.
I prov id ed a vict im impac t st at ement f or cou rt
If yo u se lect YES we will ch eck the o ffe nd er’s file to en sur e we h ave a cop y.
PLE ASE ENSURE THAT PARTS A TO C ARE COM PLETED.
If yo u req uir e mo re spa ce tha n wh at is pr ovide d on thi s ap plication for m, plea se u se and in clude an ad dition al pie ce o f
pap er, with you r signa ture and the date .
Pa rt A – Re ques t to re ce iv e infor ma tion
CSC a nd PBC can pro vid e cer ta in infor mation a bo ut o ffe nd ers onl y to peo ple who mee t the d efinition o f ‘victim’ ( 1 and
d
2) or mee t othe r criter ia (3) th at app ea r in th e Corrections and Conditional Release Act (CCRA) . In this p ar t, yo u wil l
pro vid e infor mation th at a llows CSC an d PBC to de te rm ine if you m eet th e de fin itio n or cr ite ria.
Yo u ne ed to comp lete th e one se ction tha t cor re sp on ds to you r situ ation.
ion.
If yo u se lect ( 1) g o to A1 of th e app lica tion for m.
If yo u se lect ( 2) g o to A2 of th e app lica tion for m.
If yo u se lect ( 3) g o to A3 of th e app lica tion for m.
.
A1) I w as har med (s uff ere d a los s or hav e be en phy sically or emot ionally hurt ) as a resu lt o f a criminal off enc e
This se ction a llows pe op le to req ue st infor mation a bou t o ffend ers wh o ha rm ed them o r ha rme d so meo ne with who m
th ey h ave a close an d dir ect r elation ship, an d allo ws p eo ple who wer e ha rm ed b y th eir con ne ction with the offe nce to
receive the in fo rm atio n. Ch eck the b ox in th is section if o ne o f the se o ption s a pplie s to yo ur situa tio n an d if the o ffe nd er
was convicte d for the com mission o f the o ffe nce.
Off enc e( s)
In dica te all of th e offen ce s tha t ha rm ed you an d for which the o ffe nde r was con victed , re sulting in th e cu rr ent senten ce.
(Infor mation a bou t p re vio us se ntences, if ap plicab le, is no t re qu ir ed .).
Se le ct o ne of th e following ( A, B or C) . Select the option that applies to your situation.
A. The of fe nce w as co mmitt ed ag ainst me .
Exam ple: I am th e per so n who was assa ulted b y the o ffend er.
B. The of fe nce w as co mmitt ed ag ainst s omeone w ith w hom I hav e a close a nd direc t rela tionsh ip . Name of
of
the pe rson . My re lations hip to th e pers on is:
Exam ple 1: I a m th e husb and o f the wo man who was assaulte d by th e offend er.
Exam ple 2: I a m th e moth er of the 5 year -o ld bo y who was assaulted by the offend er .
C. I hav e a co nnec tion to t he off enc e. (Indicat e y our con nect ion)
n)
Exam ple 1: I was in th e ba nk wh ile it was b ein g ro bbe d an d was n am ed in the p olice rep or t.
Exam ple 2: I a m th e cle rk wh o wa s wor kin g at th e sto re whe n it was r ob be d an d pr ovide d a victim im pa ct
statem ent to th e co ur t.
PBC/CLCC 00 31E (R-2014- 11) (Word Version & PDF) Pa ge 9 of 11
Also availa ble at CSC/SCC 1429E
Voir le formulai re P BC/CLCC 00 31F o u CSC/SCC 142 9F pou r la version fr ançaise
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