{"id":960,"date":"2018-12-17T02:22:28","date_gmt":"2018-12-17T06:22:28","guid":{"rendered":"https:\/\/www.programmeproches.ca\/?page_id=960"},"modified":"2021-05-18T16:50:25","modified_gmt":"2021-05-18T20:50:25","slug":"reimbursement-form-for-applicant-and-companion","status":"publish","type":"page","link":"https:\/\/www.programmeproches.ca\/en\/forms\/reimbursement-form-for-applicant-and-companion\/","title":{"rendered":"Reimbursement form for applicant and companion"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column][vc_column_text]<\/p>\n<h1>Reimbursement form for applicant and companion<\/h1>\n<hr \/>\n<h2><\/h2>\n<p>[\/vc_column_text][vc_column_text css=&#8221;.vc_custom_1620762932603{padding-top: 4% !important;padding-right: 6% !important;padding-bottom: 4% !important;padding-left: 6% !important;background-color: #fffbf4 !important;}&#8221;]To print, use the <a href=\"https:\/\/www.programmeproches.ca\/wp-content\/uploads\/2021\/05\/Proches-Reimbursement-Form_En_21-05.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">PDF version<\/a> of the form.[\/vc_column_text][vc_column_text]<\/p>\n<hr \/>\n<h2>General information<\/h2>\n<p>[\/vc_column_text][\/vc_column][\/vc_row][vc_row text_style=&#8221;&#8221; animation=&#8221;&#8221; animation_delay=&#8221;200&#8243; css=&#8221;.vc_custom_1545024357518{padding-top: 4% !important;padding-right: 6% !important;padding-bottom: 4% !important;padding-left: 6% !important;background-color: #fffbf4 !important;}&#8221; el_id=&#8221;&#8221;][vc_column][vc_column_text css=&#8221;.vc_custom_1621370904299{padding-top: 4% !important;padding-right: 6% !important;padding-bottom: 4% !important;padding-left: 6% !important;background-color: #fffbf4 !important;}&#8221;]Complete this form <span style=\"text-decoration: underline;\"><strong>only if you or the person you are accompanying has already completed an <a href=\"https:\/\/www.programmeproches.ca\/en\/forms\/application-form\/\" target=\"_blank\" rel=\"noopener noreferrer\">Application Form<\/a><\/strong><\/span>.<\/p>\n<p>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]Please complete <span style=\"text-decoration: underline;\">one Request for Reimbursement form for each beneficiary<\/span>.<\/p>\n<p>Note: \u201cBeneficiary\u201d 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.<\/p>\n<p>If you would like assistance in completing your form, please contact one of the following resources:<\/p>\n<ul>\n<li>Crime Victim Assistance Centres (CAVAC): <strong>1-866-LE CAVAC<\/strong> (532-2822)<\/li>\n<li><em>Association des familles de personnes assassin\u00e9es ou disparues<\/em> (AFPAD) \u2013 association of families of homicide victims or missing persons: <strong>1-877-484-0404<\/strong><\/li>\n<li>MADD Canada \u2013 Mothers Against Drunk Driving:<strong> 1-877-392-6233<\/strong><\/li>\n<\/ul>\n<hr \/>\n<h2>Procedure<\/h2>\n<p>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.<\/p>\n<p><strong>Preparing your Request for Reimbursement<\/strong><\/p>\n<p>Gather together all your supporting documents and enter the required information on the form.<br \/>\nSupporting documents to be included with your reimbursement request:<\/p>\n<ul>\n<li>Proof of address<\/li>\n<li>Parking receipts<\/li>\n<li>Restaurant receipts<\/li>\n<li>Hotel receipts<\/li>\n<li>Receipts for transportation: bus, taxi, plane, etc.<\/li>\n<li>Any other receipts<\/li>\n<\/ul>\n<p>Supporting documents included with your request may be in the form of photos or PDF documents. Be sure to <strong>keep the originals<\/strong>, however, as they must be provided on request.<\/p>\n<p><strong>Acknowledgement of receipt <\/strong><\/p>\n<p>You will receive a printable version of the form by email once you have completed and submitted it.<\/p>\n<hr \/>\n<h2>After you have submitted your form<\/h2>\n<p>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.<\/p>\n<hr \/>\n<h2>Notice of collection of personal information<\/h2>\n<p>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 <em>Act respecting the protection of personal information in the private sector<\/em><em> (chapter P\u201139.1), <\/em>your information will not be shared with any third-party organizations.<\/p>\n<hr \/>\n<h2>Additional information<\/h2>\n<p>Please do not hesitate to contact us if you have any questions or require more information. Write to us at\u00a0 <a href=\"mailto:demande@programmeproches.ca\">demande@programmeproches.ca<\/a> or call 514-277-9860, ext. 2234.[\/vc_column_text]<div class=\"grve-element grve-hr \" style=\"padding-top: 4%;padding-bottom: 4%;\"><div class=\"grve-line-divider\"><\/div><\/div>[\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]<\/p>\n<h1><a id=\"reimbursement\"><\/a>Request for Reimbursement<\/h1>\n<p>[\/vc_column_text][vc_column_text]<a href=\"#save\">You can make a backup of the form if you have not finished filling. (Available at the end of the form).<\/a><\/p>\n<p>An asterisk (<span style=\"color: #ff0000;\"><strong>*<\/strong><\/span>) indicates a compulsory field.[\/vc_column_text][vc_column_text el_id=&#8221;true -&gt;&#8221;][\/vc_column_text]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_9'  action='\/en\/wp-json\/wp\/v2\/pages\/960#gf_9' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_9_205\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_205'>Email<\/label><div class='ginput_container'><input name='input_205' id='input_9_205' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_9_205'>This field is for validation 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                <span id='input_9_76_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_9_76_3' class='gform-field-label gform-field-label--type-sub '>First name<\/label>\n                                                    <input type='text' name='input_76.3' id='input_9_76_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_9_76_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_9_76_6' class='gform-field-label gform-field-label--type-sub '>Last name<\/label>\n                                                            <input type='text' name='input_76.6' id='input_9_76_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_9_8\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_8'>Telephone number\u200a\u200a<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_9_8' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><fieldset id=\"field_9_10\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_9_10_container'>\n                                <span id='input_9_10_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_9_10' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                    <input class='' type='email' name='input_10' id='input_9_10' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                <\/span>\n                                <span id='input_9_10_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_9_10_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                    <input class='' type='email' name='input_10_2' id='input_9_10_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_9_96\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_96'>Applicant\u2019s file number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_9_96'>The file number is indicated in your letter of acceptance.<\/div><div class='ginput_container ginput_container_text'><input name='input_96' id='input_9_96' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_96\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_201\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full bloc-note gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If you have not been recognized as an applicant under this program and are instead a <strong>companion<\/strong>, please complete <strong>Section B<\/strong>.<\/div><fieldset id=\"field_9_204\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I am a companion :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_204'>\n\t\t\t<div class='gchoice gchoice_9_204_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='No' checked='checked' id='choice_9_204_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_204_0' id='label_9_204_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_204_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='Yes, please complete Section B'  id='choice_9_204_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_204_1' id='label_9_204_1' class='gform-field-label gform-field-label--type-inline'>Yes, please complete Section B<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_100\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">B- Additional informations<\/h3><\/div><div id=\"field_9_202\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full bloc-note gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Complete this section only if you are accompanying an applicant (in other words, if you are not an accepted applicant yourself).<\/div><fieldset id=\"field_9_171\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_9_171' class='ginput_container ginput_complex gform-grid-row'>\n                                            <div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_9_171_3_container'>\n                                                <input type='number' maxlength='4' name='input_171[]' id='input_9_171_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                                <label for='input_9_171_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_9_171_1_container'>\n                                                <input type='number' maxlength='2' name='input_171[]' id='input_9_171_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                                <label for='input_9_171_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                            <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_9_171_2_container'>\n                                                <input type='number' maxlength='2' name='input_171[]' id='input_9_171_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                                <label for='input_9_171_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                           <\/div>\n                                        <\/div><\/fieldset><div id=\"field_9_172\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_172'>Sex<\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_9_172' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div data-fieldId=\"172\" class=\"spacer gfield\" style=\"grid-column: span 9;\" data-groupId=\"9c6f52eb\"><\/div><fieldset id=\"field_9_173\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Complete address\u200a<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_9_173' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_173_1_container' >\n                                        <input type='text' name='input_173.1' id='input_9_173_1' value=''    aria-required='false'    \/>\n                                        <label for='input_9_173_1' id='input_9_173_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_173_3_container' >\n                                    <input type='text' name='input_173.3' id='input_9_173_3' value=''    aria-required='false'    \/>\n                                    <label for='input_9_173_3' id='input_9_173_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_173_4_container' >\n                                        <input type='text' name='input_173.4' id='input_9_173_4' value=''      aria-required='false'    \/>\n                                        <label for='input_9_173_4' id='input_9_173_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_173_5_container' >\n                                    <input type='text' name='input_173.5' id='input_9_173_5' value=''    aria-required='false'    \/>\n                                    <label for='input_9_173_5' id='input_9_173_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_9_173_6_container' >\n                                        <select name='input_173.6' id='input_9_173_6'   aria-required='false'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' selected='selected'>Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_9_173_6' id='input_9_173_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_9_174\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Language of correspondence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_174'>\n\t\t\t<div class='gchoice gchoice_9_174_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_174' type='radio' value='English' checked='checked' id='choice_9_174_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_174_0' id='label_9_174_0' class='gform-field-label gform-field-label--type-inline'>English<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_174_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_174' type='radio' value='French'  id='choice_9_174_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_174_1' id='label_9_174_1' class='gform-field-label gform-field-label--type-inline'>French<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_175\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_175'>Name of the applicant you are accompanying:<\/label><div class='ginput_container ginput_container_text'><input name='input_175' id='input_9_175' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_176\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_176'>Applicant\u2019s file number<\/label><div class='ginput_container ginput_container_text'><input name='input_176' id='input_9_176' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_176\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_9_176'>Note that we may contact the applicant for verification purposes.<\/div><\/div><div id=\"field_9_12\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_12'>What is your relationship to the victim?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_9_12'>N.B.: You are considered to be the victim\u2019s spouse if you were joined by marriage or civil union, or if you considered yourselves as spouses in a civil union and had been living together as a couple for at least one year, had\/will have a child together, had adopted a child together or if one of you had adopted the child of the other during your union.<\/div><div class='ginput_container ginput_container_select'><select name='input_12' id='input_9_12' class='medium gfield_select'  aria-describedby=\"gfield_description_9_12\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Spouse' >Spouse<\/option><option value='Child' >Child<\/option><option value='Parent' >Parent<\/option><option value='Brother \/ sister' >Brother \/ sister<\/option><option value='Grandparent' >Grandparent<\/option><option value='Intimate partner \u2013 date of beginning of relationship' >Intimate partner \u2013 date of beginning of relationship<\/option><option value='Child of victim\u2019s spouse' >Child of victim\u2019s spouse<\/option><option value='Spouse of victim\u2019s parent' >Spouse of victim\u2019s parent<\/option><option value='Uncle \/ aunt' >Uncle \/ aunt<\/option><option value='Nephew \/ niece' >Nephew \/ niece<\/option><option value='Cousin' >Cousin<\/option><option value='Parent of victim\u2019s spouse' >Parent of victim\u2019s spouse<\/option><option value='Child\u2019s spouse' >Child\u2019s spouse<\/option><option value='Friend' >Friend<\/option><option value='Work colleague' >Work colleague<\/option><option value='Other \u2013 please specify:' >Other \u2013 please specify:<\/option><\/select><\/div><\/div><fieldset id=\"field_9_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Statuts:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_13'>\n\t\t\t<div class='gchoice gchoice_9_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Married'  id='choice_9_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_13_0' id='label_9_13_0' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Civil union'  id='choice_9_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_13_1' id='label_9_13_1' class='gform-field-label gform-field-label--type-inline'>Civil union<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='De facto (common-law) spouse \u2013 date when you started living together'  id='choice_9_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_13_2' id='label_9_13_2' class='gform-field-label gform-field-label--type-inline'>De facto (common-law) spouse \u2013 date when you started living together<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Spouse with child(ren)'  id='choice_9_13_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_13_3' id='label_9_13_3' class='gform-field-label gform-field-label--type-inline'>Spouse with child(ren)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_14\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Intimate partner<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_9_14'>Date of beginning of relationship:<\/div><div id='input_9_14' class='ginput_container ginput_complex gform-grid-row'>\n                                            <div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_9_14_3_container'>\n                                                <input type='number' maxlength='4' name='input_14[]' id='input_9_14_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                                <label for='input_9_14_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_9_14_1_container'>\n                                                <input type='number' maxlength='2' name='input_14[]' id='input_9_14_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                                <label for='input_9_14_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                            <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_9_14_2_container'>\n                                                <input type='number' maxlength='2' name='input_14[]' id='input_9_14_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                                <label for='input_9_14_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                           <\/div>\n                                        <\/div><\/fieldset><fieldset id=\"field_9_74\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >De facto (common-law) spouse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_9_74'>Date when you started living together:<\/div><div id='input_9_74' class='ginput_container ginput_complex gform-grid-row'>\n                                            <div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_9_74_3_container'>\n                                                <input type='number' maxlength='4' name='input_74[]' id='input_9_74_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                                <label for='input_9_74_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_9_74_1_container'>\n                                                <input type='number' maxlength='2' name='input_74[]' id='input_9_74_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                                <label for='input_9_74_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                            <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_9_74_2_container'>\n                                                <input type='number' maxlength='2' name='input_74[]' id='input_9_74_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                                <label for='input_9_74_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                           <\/div>\n                                        <\/div><\/fieldset><div id=\"field_9_15\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_15'>Other\u00a0:<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_9_15' type='text' value='' class='medium'    placeholder='Please specify'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_46\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_46'>Are you a member of an ethnocultural minority?<\/label><div class='gfield_description' id='gfield_description_9_46'>If so, please specify:<\/div><div class='ginput_container ginput_container_text'><input name='input_46' id='input_9_46' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_46\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_47\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_47'>Are you a member of a First Nation?<\/label><div class='gfield_description' id='gfield_description_9_47'>If so, please specify:<\/div><div class='ginput_container ginput_container_text'><input name='input_47' id='input_9_47' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_47\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_48\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_48'>Are you living with a disability?<\/label><div class='gfield_description' id='gfield_description_9_48'>If so, please specify: <\/div><div class='ginput_container ginput_container_text'><input name='input_48' id='input_9_48' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_48\"    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently receiving or have you ever received services from a CAVAC (Crime Victim Assistance Centre)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_80'>\n\t\t\t<div class='gchoice gchoice_9_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No' checked='checked' id='choice_9_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_80_0' id='label_9_80_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='If so, which one (which region)?'  id='choice_9_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_80_1' id='label_9_80_1' class='gform-field-label gform-field-label--type-inline'>If so, which one (which region)?<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_52\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_52'>CAVAC region?<\/label><div class='gfield_description' id='gfield_description_9_52'>Which region?<\/div><div class='ginput_container ginput_container_text'><input name='input_52' id='input_9_52' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_52\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_81\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_9_81'>Name of CAVAC worker<\/label><div class='gfield_description' id='gfield_description_9_81'>Name of CAVAC worker<\/div><div class='ginput_container ginput_container_text'><input name='input_81' id='input_9_81' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_81\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_166\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_9_166'>CAVAC Contact information<\/label><div class='gfield_description' id='gfield_description_9_166'>CAVAC Contact information<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_166' id='input_9_166' class='textarea small'  aria-describedby=\"gfield_description_9_166\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_9_168\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you authorize us to exchange information with this organization in order to help you with your current situation as someone close to a victim who incurred travel expenses in order to attend legal proceedings\u2009?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_168'>\n\t\t\t<div class='gchoice gchoice_9_168_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='Yes'  id='choice_9_168_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_168_0' id='label_9_168_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_168_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='No'  id='choice_9_168_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_168_1' id='label_9_168_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_82\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently receiving or have you ever received  services from another organization in connection with  the death of your loved one?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_82'>\n\t\t\t<div class='gchoice gchoice_9_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='No' checked='checked' id='choice_9_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_82_0' id='label_9_82_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='If so, please specify the name of the organization'  id='choice_9_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_82_1' id='label_9_82_1' class='gform-field-label gform-field-label--type-inline'>If so, please specify the name of the organization<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_83\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_9_83'>Specify the name of the organization:<\/label><div class='gfield_description' id='gfield_description_9_83'>Specify the name of the organization:<\/div><div class='ginput_container ginput_container_text'><input name='input_83' id='input_9_83' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_83\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_165\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_9_165'>Name of worker:<\/label><div class='gfield_description' id='gfield_description_9_165'>Name of worker:<\/div><div class='ginput_container ginput_container_text'><input name='input_165' id='input_9_165' type='text' value='' class='medium'  aria-describedby=\"gfield_description_9_165\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_85\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_9_85'>Contact information:<\/label><div class='gfield_description' id='gfield_description_9_85'>Contact information:<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_85' id='input_9_85' class='textarea small'  aria-describedby=\"gfield_description_9_85\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_9_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you authorize us to exchange information with this organization in order to help you with your current situation as someone close to a victim who incurred travel expenses in order to attend legal proceedings?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_59'>\n\t\t\t<div class='gchoice gchoice_9_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Yes'  id='choice_9_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_59_0' id='label_9_59_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='No'  id='choice_9_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_59_1' id='label_9_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_101\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">C- Period covered by the reimbursement request<\/h3><\/div><fieldset id=\"field_9_177\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >List - Period covered by the reimbursement request<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dates of hearing days you attended  (YYYY\/MM\/DD)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Location of hearings held<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name of companion (if applicable)<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_177_cell1 gform-grid-col' data-label='Dates of hearing days you attended  (YYYY\/MM\/DD)'><input aria-invalid='false'   aria-label='Dates of hearing days you attended  (YYYY\/MM\/DD), Row 1' data-aria-label-template='Dates of hearing days you attended  (YYYY\/MM\/DD), Row {0}' type='text' name='input_177[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_177_cell2 gform-grid-col' data-label='Location of hearings held'><input aria-invalid='false'   aria-label='Location of hearings held, Row 1' data-aria-label-template='Location of hearings held, Row {0}' type='text' name='input_177[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_177_cell3 gform-grid-col' data-label='Name of companion (if applicable)'><input aria-invalid='false'   aria-label='Name of companion (if applicable), Row 1' data-aria-label-template='Name of companion (if applicable), Row {0}' type='text' name='input_177[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 10)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 10)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_9_203\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full .bloc-note gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please include your companion\u2019s expenses on this form only if you wish to obtain the reimbursements to which the companion is\nentitled. In this case, please note that your companion will not be\nable to complete a reimbursement form for these same days. <\/div><fieldset id=\"field_9_167\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Were you summoned to appear in court on one or other of these dates?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_167'>\n\t\t\t<div class='gchoice gchoice_9_167_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='No'  id='choice_9_167_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_167_0' id='label_9_167_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_167_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Yes \u2013 please specify all dates:'  id='choice_9_167_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_167_1' id='label_9_167_1' class='gform-field-label gform-field-label--type-inline'>Yes \u2013 please specify all dates:<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_121\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_121'>Specify all dates:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_121' id='input_9_121' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_9_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_28'>Add any other details you feel are necessary:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_9_28' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_9_104\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">D- Transportation and parking<\/h3><\/div><div id=\"field_9_105\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>You may claim any transportation expenses (bus, train, plane, etc.) you incurred to travel to the courthouse or back to your residence.<\/p>\n<p>If you travelled to and from the courthouse by car, you are entitled to $0.640 for every kilometer travelled. If you use your car, you are entitled to be reimbursed for your parking fees.<\/p>\n<hr><\/div><fieldset id=\"field_9_127\" class=\"gfield gfield--type-list gfield--input-type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >List - Transportation and parking<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Day (YYYY-MM-DD)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Mode of transport<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Ticket price ($)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Mileage travelled (Km)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Cost of parking ($)<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_127_cell1 gform-grid-col' data-label='Day (YYYY-MM-DD)'><input aria-invalid='false'   aria-label='Day (YYYY-MM-DD), Row 1' data-aria-label-template='Day (YYYY-MM-DD), Row {0}' type='text' name='input_127[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_127_cell2 gform-grid-col' data-label='Mode of transport'><input aria-invalid='false'   aria-label='Mode of transport, Row 1' data-aria-label-template='Mode of transport, Row {0}' type='text' name='input_127[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_127_cell3 gform-grid-col' data-label='Ticket price ($)'><input aria-invalid='false'   aria-label='Ticket price ($), Row 1' data-aria-label-template='Ticket price ($), Row {0}' type='text' name='input_127[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_127_cell4 gform-grid-col' data-label='Mileage travelled (Km)'><input aria-invalid='false'   aria-label='Mileage travelled (Km), Row 1' data-aria-label-template='Mileage travelled (Km), Row {0}' type='text' name='input_127[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_127_cell5 gform-grid-col' data-label='Cost of parking ($)'><input aria-invalid='false'   aria-label='Cost of parking ($), Row 1' data-aria-label-template='Cost of parking ($), Row {0}' type='text' name='input_127[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 30)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 30)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_9_123\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_123'>If the mileage travelled is different from the distance between your home and the courthouse address where the hearings were held, please explain why:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_123' id='input_9_123' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_9_190\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_9_190'>Include receipts and proof of address (photo or pdf - max 3 MB \/ file) *<\/label><div class='gfield_description' id='gfield_description_9_190'>If you traveled using your vehicle, you must attach proof of address to calculate your mileage.\n\nYou must include all your receipts in order to be eligible for reimbursement. Receipts are not required, however, in the case of public transportation, such as subway or city bus. Unless you provide receipts indicating otherwise, a maximum of $7\/day (or $3.50 each way) will be reimbursed for public transportation.<\/div><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_9_190' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_9_190&quot;,&quot;container&quot;:&quot;gform_multifile_upload_9_190&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_9_190&quot;,&quot;filelist&quot;:&quot;gform_preview_9_190&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.programmeproches.ca\\\/en\\\/?gf_page=05366ffecd667b4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.programmeproches.ca\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.programmeproches.ca\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,doc,docx&quot;}],&quot;max_file_size&quot;:&quot;3145728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:9,&quot;field_id&quot;:190,&quot;_gform_file_upload_nonce_9_190&quot;:&quot;135ea4b571&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;50&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_9_190&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_9_190' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_9_190' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_9_190 gfield_description_9_190\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_9_190'>Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 3 MB, Max. files: 50.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_9_190'><\/ul> <div id='gform_preview_9_190' class='ginput_preview_list'><\/div><\/div><\/div><fieldset id=\"field_9_189\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If you do not have parking receipts, indicate exactly where your car was parked (for parking rate verification when possible):<\/legend><div class='ginput_container ginput_container_list ginput_list '><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_189_cell1 gform-grid-col' ><input aria-invalid='false'   aria-label='If you do not have parking receipts, indicate exactly where your car was parked (for parking rate verification when possible):, Row 1' data-aria-label-template='If you do not have parking receipts, indicate exactly where your car was parked (for parking rate verification when possible):, Row {0}' type='text' name='input_189[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 30)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 30)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_9_124\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">E- Meals<\/h3><\/div><div id=\"field_9_191\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full .bloc-note gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >You may claim up to <strong>$66.65\/day<\/strong> for meals:\n<ul>\n  <li>$14.95 for breakfast (breakfast is reimbursed if you had to leave home before 7:30 a.m.)<\/li>\n  <li>$20.60 for lunch (lunch is reimbursed if you were away from home after 1:00 p.m. or, in the case of an afternoon hearing only, you had to leave home before 11:30 a.m.)<\/li>\n  <li>$31.10 for dinner or an evening meal (dinner is reimbursed if you were away from home after 7:00 p.m.).<\/li>\n<\/ul>  \n\n<p>These amounts include tips and taxes. Also note that amounts for alcoholic beverages will be deducted from the amounts awarded. These rates may be higher in certain municipalities north of the 49<sup>th<\/sup> parallel. More information is available on our website at programmeproches.ca, under the <a href=\"https:\/\/programmeproches.ca\/en\/reimbursement-amounts\/\" target=\"_blank\">Reimbursement Amounts <\/a> tab.<\/p>\n<hr><\/div><div id=\"field_9_125\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_9_125'>Include receipts (restaurants or groceries): (photo or pdf - max 3 MB \/ file) *<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_9_125' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_9_125&quot;,&quot;container&quot;:&quot;gform_multifile_upload_9_125&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_9_125&quot;,&quot;filelist&quot;:&quot;gform_preview_9_125&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.programmeproches.ca\\\/en\\\/?gf_page=05366ffecd667b4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.programmeproches.ca\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.programmeproches.ca\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,doc,docx&quot;}],&quot;max_file_size&quot;:&quot;3145728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:9,&quot;field_id&quot;:125,&quot;_gform_file_upload_nonce_9_125&quot;:&quot;94315df274&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;50&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_9_125&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_9_125' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_9_125' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_9_125\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_9_125'>Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 3 MB, Max. files: 50.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_9_125'><\/ul> <div id='gform_preview_9_125' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_9_128\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">F- Accommodation<\/h3><\/div><div id=\"field_9_192\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full .bloc-note gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If your residence is at a considerable distance from the courthouse or the legal proceedings extend over several days, you are eligible for an accommodation allowance if you chose to sleep at a hotel (or other establishment, such as an Airbnb). This allowance ranges from $101 to $177 for one night, depending on the region and the time of year. More information is available on our website at programmeproches.ca, under the Reimbursement Amounts tab.\n<hr><\/div><fieldset id=\"field_9_126\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >receipts - Transportation<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Accommodation date (yyyy\/mm\/dd)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Amount disbursed ($)<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_126_cell1 gform-grid-col' data-label='Accommodation date (yyyy\/mm\/dd)'><input aria-invalid='false'   aria-label='Accommodation date (yyyy\/mm\/dd), Row 1' data-aria-label-template='Accommodation date (yyyy\/mm\/dd), Row {0}' type='text' name='input_126[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_126_cell2 gform-grid-col' data-label='Amount disbursed ($)'><input aria-invalid='false'   aria-label='Amount disbursed ($), Row 1' data-aria-label-template='Amount disbursed ($), Row {0}' type='text' name='input_126[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 50)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 50)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_9_130\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_9_130'>Provide receipts and proof of address (photo or pdf - max 3 MB \/ file) *<\/label><div class='gfield_description' id='gfield_description_9_130'>You must enclose all your receipts in order to obtain a reimbursement.<\/div><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_9_130' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_9_130&quot;,&quot;container&quot;:&quot;gform_multifile_upload_9_130&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_9_130&quot;,&quot;filelist&quot;:&quot;gform_preview_9_130&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.programmeproches.ca\\\/en\\\/?gf_page=05366ffecd667b4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.programmeproches.ca\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.programmeproches.ca\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,doc,docx&quot;}],&quot;max_file_size&quot;:&quot;3145728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:9,&quot;field_id&quot;:130,&quot;_gform_file_upload_nonce_9_130&quot;:&quot;7f82becf94&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;50&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_9_130&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_9_130' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_9_130' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_9_130 gfield_description_9_130\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_9_130'>Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 3 MB, Max. files: 50.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_9_130'><\/ul> <div id='gform_preview_9_130' class='ginput_preview_list'><\/div><\/div><\/div><fieldset id=\"field_9_200\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you sleep at a parent\u2019s or friend\u2019s house instead?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_200'>\n\t\t\t<div class='gchoice gchoice_9_200_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_200' type='radio' value='No' checked='checked' id='choice_9_200_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_200_0' id='label_9_200_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_200_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_200' type='radio' value='If you slept at the home of a relative or friend, you are entitled to compensation in the amount of $22.25\/night.'  id='choice_9_200_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_200_1' id='label_9_200_1' class='gform-field-label gform-field-label--type-inline'>If you slept at the home of a relative or friend, you are entitled to compensation in the amount of $22.25\/night.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_155\" class=\"gfield gfield--type-list gfield--input-type-list field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Slept at the home of a relative or friend<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Address<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dates (YYYY\/MM\/DD)<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_155_cell1 gform-grid-col' data-label='Address'><input aria-invalid='false'   aria-label='Address, Row 1' data-aria-label-template='Address, Row {0}' type='text' name='input_155[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_155_cell2 gform-grid-col' data-label='Dates (YYYY\/MM\/DD)'><input aria-invalid='false'   aria-label='Dates (YYYY\/MM\/DD), Row 1' data-aria-label-template='Dates (YYYY\/MM\/DD), Row {0}' type='text' name='input_155[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 50)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 50)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_9_63\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">G- Declaration<\/h3><\/div><fieldset id=\"field_9_65\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I declare that the information provided<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_65.1' id='input_9_65_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_65_1' >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.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_65.2' value='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.' class='gform_hidden' \/><input type='hidden' name='input_65.3' value='25' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_9_195\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I confirm that the expenses submitted for reimbursement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_195.1' id='input_9_195_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_195_1' >I confirm that the expenses submitted for reimbursement to the Quebec Reimbursement Program for Family and Close Friends of Deceased Victims of a Criminal Act have not already been and\/or will not be reimbursed by another program.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_195.2' value='I confirm that the expenses submitted for reimbursement to the Quebec Reimbursement Program for Family and Close Friends of Deceased Victims of a Criminal Act have not already been and\/or will not be reimbursed by another program.' class='gform_hidden' \/><input type='hidden' name='input_195.3' value='25' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_9_71\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_9_71' class='ginput_container ginput_complex gform-grid-row'>\n                                            <div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_9_71_3_container'>\n                                                <input type='number' maxlength='4' name='input_71[]' id='input_9_71_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                                <label for='input_9_71_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_9_71_1_container'>\n                                                <input type='number' maxlength='2' name='input_71[]' id='input_9_71_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                                <label for='input_9_71_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                            <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_9_71_2_container'>\n                                                <input type='number' maxlength='2' name='input_71[]' id='input_9_71_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                                <label for='input_9_71_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                           <\/div>\n                                        <\/div><\/fieldset><fieldset id=\"field_9_196\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I wish to be reimbursed by :<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_196'>\n\t\t\t<div class='gchoice gchoice_9_196_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_196' type='radio' value='Bank transfer (faster)'  id='choice_9_196_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_196_0' id='label_9_196_0' class='gform-field-label gform-field-label--type-inline'>Bank transfer (faster)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_196_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_196' type='radio' value='Cheque sent by mail'  id='choice_9_196_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_196_1' id='label_9_196_1' class='gform-field-label gform-field-label--type-inline'>Cheque sent by mail<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_197\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_9_197'>Attach a void sample cheque in your name to the form:<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_9_197' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_9_197&quot;,&quot;container&quot;:&quot;gform_multifile_upload_9_197&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_9_197&quot;,&quot;filelist&quot;:&quot;gform_preview_9_197&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.programmeproches.ca\\\/en\\\/?gf_page=05366ffecd667b4&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.programmeproches.ca\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.programmeproches.ca\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,gif,png,pdf,doc,docx&quot;}],&quot;max_file_size&quot;:&quot;3145728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:9,&quot;field_id&quot;:197,&quot;_gform_file_upload_nonce_9_197&quot;:&quot;d1b11074b9&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;2&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_9_197&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_9_197' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_9_197' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_9_197\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_9_197'>Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 3 MB, Max. files: 2.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_9_197'><\/ul> <div id='gform_preview_9_197' class='ginput_preview_list'><\/div><\/div><\/div><fieldset id=\"field_9_198\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please confirm your mailing address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_9_198' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_198_1_container' >\n                                        <label for='input_9_198_1' id='input_9_198_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_198.1' id='input_9_198_1' value=''    aria-required='false'   autocomplete=\"address-line1\" \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_198_3_container' >\n                                    <label for='input_9_198_3' id='input_9_198_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_198.3' id='input_9_198_3' value=''    aria-required='false'   autocomplete=\"address-level2\" \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_198_4_container' >\n                                        <label for='input_9_198_4' id='input_9_198_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_198.4' id='input_9_198_4' value=''      aria-required='false'   autocomplete=\"address-level1\" \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_198_5_container' >\n                                    <label for='input_9_198_5' id='input_9_198_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_198.5' id='input_9_198_5' value=''    aria-required='false'   autocomplete=\"postal-code\" \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_9_198_6_container' >\n                                        <label for='input_9_198_6' id='input_9_198_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_198.6' id='input_9_198_6'   aria-required='false'   autocomplete=\"country-name\" ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' selected='selected'>Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_9_164\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are the applicant is under 18 years of age?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_164'>\n\t\t\t<div class='gchoice gchoice_9_164_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_164' type='radio' value='No' checked='checked' id='choice_9_164_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_164_0' id='label_9_164_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_164_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_164' type='radio' value='Yes'  id='choice_9_164_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_164_1' id='label_9_164_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_159\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">H- Complete this section only if the applicant is under 18 years of age*<\/h3><\/div><fieldset id=\"field_9_160\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name of legal guardian<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_160'>\n                            \n                            <span id='input_9_160_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_160.3' id='input_9_160_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_160_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_9_160_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_160.6' id='input_9_160_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_160_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_9_161\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Signature of guardian<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_161.1' id='input_9_161_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_9_161_1' >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.<\/label><input type='hidden' name='input_161.2' value='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.' class='gform_hidden' \/><input type='hidden' name='input_161.3' value='25' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_9_162\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date<\/legend><div id='input_9_162' class='ginput_container ginput_complex gform-grid-row'>\n                                            <div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_9_162_3_container'>\n                                                <input type='number' maxlength='4' name='input_162[]' id='input_9_162_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                                <label for='input_9_162_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_9_162_1_container'>\n                                                <input type='number' maxlength='2' name='input_162[]' id='input_9_162_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                                <label for='input_9_162_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                            <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_9_162_2_container'>\n                                                <input type='number' maxlength='2' name='input_162[]' id='input_9_162_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                                <label for='input_9_162_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                           <\/div>\n                                        <\/div><\/fieldset><div id=\"field_9_163\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_163'>Guardian\u2019s email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_163' id='input_9_163' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_9_193\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Additional space<\/h3><\/div><fieldset id=\"field_9_186\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Additional space for your answers:<\/legend><div class='ginput_container ginput_container_list ginput_list '><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_186_cell1 gform-grid-col' ><input aria-invalid='false'   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