Guide for completing the Request for Decision Review form

To print, use the PDF version of the form.

General information

Complete this request form only if you have already completed an Application Form and would like us to review the decision made regarding your file. Please note that the Request for Decision Review form must be sent to us within five business days of your receipt of the original decision.

If you would like assistance in completing your form, please contact one of the following resources:

Crime Victim Assistance Centres (CAVAC): 1-866-LE CAVAC (532-2822)
Association des familles de personnes assassinées ou disparues (AFPAD) – association of families of homicide victims or missing persons: 1-877-484-0404
MADD Canada – Mothers Against Drunk Driving: 1-877-392-6233

Procedure

You must enter all the required information in the correct fields. Forms with incorrect or incomplete information may cause a delay in processing your application.

Acknowledgement of receipt

You will receive a printable version of the form by email once you have completed and submitted it.

After you have submitted your form

You will be notified in writing of the results of your review request within 30 days. All decisions made further to a review are final.

Notice of collection of personal information

The information contained in this form is being collected for the sole purpose of administering and evaluating the Program. Access to the information you send us is reserved for authorized persons only. In accordance with the Act respecting the protection of personal information in the private sector (chapter P‑39.1), your information will not be shared with any third-party organizations.

Additional information

Please do not hesitate to contact us if you have any questions or require more information. Write to us at demande@programmeproches.ca or call 514-277-9860, ext. 2234.

Request for Decision Review

You can make a backup of the form if you have not finished filling. (Available at the end of the form).

An asterisk (*) indicates a compulsory field.

Name*
First Last
Date of birth*

Day
Month
Year
Complete address*
Street Address City State / Province / Region ZIP / Postal Code Country
Telephone numbers
- Home
- Cell
- Work
Phone*
Email address*
Enter Email Confirm Email
Applicant’s number*
N.B.: Your number is indicated in your letter of application acceptance or refusal.
Your application was*
- Accepted
- Refused – please give reason(s)
Refused reason(s):
Why would you like your application decision to be reviewed?*
Declaration
Signature*
I declare that the information provided on this form is accurate.
Any declaration of false, incomplete or misleading information will have repercussions on the processing of this application.
Date*

Day
Month
Year
Email
This field is for validation purposes and should be left unchanged.