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APPLICATION FOR FINANCIAL ASSISTANCE FOR CANADIANS VICTIMIZED ABROAD

PERSONAL INFORMATION   [ * ] Mandatory Fields

Name of Applicant :
Surname *:    Given Name *:

Travel Document Type (i.e. passport, birth certificate, student visa) *:

Citizenship *:

Passport No. and Expiry Date (Y/M/D) * :

Date of Departure from Canada (Y/M/D) *:

Status in Country (i.e. tourist, student, on business) *:

Travel Insurance? *
Yes     No    

PAYMENT

Address for mailing information and cheque :
Address in Canada  *:
If applicable, address Abroad :

Cheque payable to * :

Currency (Canadian dollars or foreign currency) - please indicate which currency * :

Tel. No. (home)  *

Tel. No. (office)

Cell Phone

Fax No.

E-mail *

Alternate Contact

Can Messages be left:  Yes No

NATURE OF VICTIMIZATION  *

Homicide   Sexual assault   Aggravated sexual assault
Assault with serious personal violence   Assault with serious personal violence against a child

Relationship to Applicant  *:
  Self      Family Member      Parent of child victim    

Location of Offence (city, country) * :

Date Offence Occurred: (Y/M/D) *

Police Report Attached *:
Yes     No    

Consular Staff Contact Information (Name, phone number) :

Have you applied for Financial Assistance from the Victims Fund before? *
Yes     No    

Previous Amount received
$

Indicate date (Y/M/D) of previous application?

ASSISTANCE REQUIRED (please provide details)

Examples of Expenses *(*more information may be required from the applicant) *:
Travel expenses of victim to return to country where crime occurred in order to attend the preliminary hearing and/or trial or equivalent process;
Travel expenses of victim to return to country where crime occurred in order to testify at the preliminary hearing and/or trial or equivalent process;
Travel expenses for a support person to be with a Canadian victimized abroad during the immediate aftermath of the crime;
Expenses for victim to return to Canada, where no other support is available;
Out of pocket expenses due to being a victim of a violent crime;
Upon return to Canada, professional counselling that would otherwise be covered by the province or territory if the crime had occurred in that jurisdiction.    

If this request is for professional counselling, is counsellor provincially designated by Victim Services? *
Yes        No    

If this request is to attend court proceedings please provide details:
Where:
When:
Duration of Proceedings (approx.):
Confirmation of Court Proceedings (e.g. copy of subpoena, letter from prosecutor, court document) :

Signature of Applicant : ___________

Date of Application : ______________