Reimbursement form for applicant and companion

General information

Please complete one Request for Reimbursement form for each beneficiary.

Note: “Beneficiary” refers to the person who incurred the expenses and who will receive the reimbursement. A beneficiary may therefore be the accepted applicant or one of his or her companions. It is not necessary for the accepted applicant to have been present at a hearing in order for another beneficiary to be reimbursed for their expenses.

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

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

Preparing your Request for Reimbursement

Gather together all your supporting documents and enter the required information on the form.
Supporting documents to be included with your reimbursement request:

• Proof of address
• Parking receipts
• Restaurant receipts
• Hotel receipts
• Receipts for transportation: bus, taxi, plane, etc.
• Any other receipts

Supporting documents included with your request may be in the form of photos or PDF documents. Be sure to keep the originals, however, as they must be provided on request.

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

The beneficiary for whom the form was completed will receive a cheque in his or her name at the address indicated on the form. Please be sure that the name and address indicated on the form are correct. For faster processing, you can also attach a void sample cheque in your name. The reimbursement will then be made in the form of a bank transfer. You will receive a confirmation email when the bank transfer is completed.

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 Reimbursement

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.