Criminal Code

This form may be used to provide a description of the physical or emotional harm, property damage or economic loss suffered by you as the result of the commission of an offence, as well as a description of the impact of the offence on you. 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 you suffered;

• • 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.

You may present a detailed account of the impact the offence has had on your life. 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 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 they relate to the offence.

Physical impact

Describe how the offence 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 offence;

• • 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 offence 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;

• • 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 offender; and

• • concerns with respect to contact between the offender 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 offence has had on you.

•  I would like to present my 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

If you completed this statement on behalf of the victim, please indicate the reasons why you did so and the nature of your relationship with the victim.

Dated this day of 20, at .

Signature of declarant