Guide for Application to Receive Information as a Victim

This page is not the official form, it is provided for information purposes only. The official form must be printed, filled out and returned.

The Corrections and Conditional Release Act (CCRA) allows the Correctional Service of Canada (CSC) and the Parole Board of Canada (PBC) to give victims of crime information about the offender who harmed them during the offender's sentence. The process of providing this information is called 'victim notification'.

This Guide contains:

  1. Information about applying to receive victim notification (Questions and answers and Annex A) (CSC, PBC)
  2. The application for requesting information (Form CSC/SCC 1429E or Form PBC/CLCC 0031E)
  3. Instructions for completing the Application to Receive Information as a Victim form (CSC, PBC)

Information About Applying to Receive Victim Notification

What is the role of the CSC and PBC?

The Correctional Service of Canada (CSC) is the federal government agency responsible under the Corrections and Conditional Release Act (CCRA) for administering sentences of individuals who received a term of two years or more, as imposed by the court. CSC is responsible for managing institutions of various security levels and supervising offenders under conditional release in the community.

The Parole Board of Canada (PBC) is an independent administrative tribunal that has the authority under the Corrections and Conditional Release Act (CCRA) to grant or deny certain types of temporary absences, as well as grant, deny, or revoke day parole and full parole for individuals who received a sentence of two years or more. The Board also has the authority to impose special conditions during an offender's statutory release and long term supervision orders.

Who can apply to receive information from CSC and PBC?

You can apply if you are 18 years old or older and are a person who:

  • has suffered harm and/or physical or emotional damage as a result of an offence for which the offender has been convicted;
  • is a spouse, family member or guardian of the person who has been harmed and is now deceased, incapacitated or underage (under 18 years old);
  • is a common-law partner of the person who was harmed and is now deceased or incapacitated and who was living with the person at the time of the person's death for a period of at least one year;
  • is a guardian of the dependant(s) of a person who has been harmed and is now deceased, incapacitated or underage (under 18 years old);
  • was harmed as a result of an offence for which the offender was not convicted, if a complaint about the act was made to police and/or the Crown.

When should I apply?

You can apply at any time while the offender is serving a federal sentence (a sentence of two years or more). (See below for information about offenders serving sentences of less than two years.)

Do I have to apply to receive victim notification?

Yes, you must submit a request. Victim notification is only provided to an individual who submits an application form and meets the legal definition or criteria of victim. If you wish to present a statement at a Parole Board hearing and/or to obtain funding to observe a Parole Board hearing you must complete different forms for those purposes.

You do not have to be registered to:

  • provide information to CSC and/or PBC for consideration in decisions;
  • observe a parole hearing;
  • obtain a written summary of PBC decisions regarding the offender through PBC's Decision Registry; or
  • receive information about an offender's judicial review under section 745.6(2.8) of the Criminal Code.

Do I have to apply separately to CSC and PBC?

No, you only need to complete one application. Both CSC and PBC have jurisdiction over federal offenders. So, when you complete the Application to Receive Information as a Victim form and receive confirmation of your registration from one agency, you will be considered for registration with the other agency as well.

What information can I receive once I am registered?

The CCRA outlines the types of information that can be provided to victims. Some information can be provided by both agencies, some by only one. See Annex A for further detail.

How will I be notified?

Notification may be provided by phone or mail, depending on your circumstances and preferences. If you wish, you may be notified through a third party such as a family member or victim services worker.

What if the offender is serving a sentence of less than two years?

If the offender is incarcerated (in prison), you may be able to receive information from Victim Services in the province where the offender is serving his/her sentence. You can obtain contact information from Public Safety Canada's National Office for Victims by calling toll-free to 1-866-525-0554 or visiting CSC's website and click on 'Provincial Partners – Services by province'.

If the offender is on conditional release (has applied for/has been granted parole), you can obtain contact information from Public Safety Canada's National Office for Victims by calling toll-free to 1-866-525-0554 or visit CSC's website and click on 'Provincial Partners – Services by province'.

How can I apply to receive victim notification from CSC and PBC?

Complete the Application to Receive Information as a Victim form of this Guide. Sign the form and mail or fax it to the CSC or PBC office you have been in contact with (see address and fax information). If you have not yet been in contact with a particular office, send it to the office nearest you.

If you have questions about completing this form, please see the Instructions. For any remaining questions, you can contact CSC Victim Services toll free at 1-866-806-2275 or PBC's toll-free victim info line at 1-866-789-4636.

Annex A – Information that CSC and PBC Can Disclose to Registered Victims

Once a victim registers with the Correctional Service of Canada (CSC) and/or the Parole Board of Canada (PBC), they will receive the following information as described in Sections 26(1)a) and 142(1)a) of the Corrections and Conditional Release Act (CCRA):

  • offender's name,
  • offence and the court of conviction,
  • sentence start date and length,
  • offender's eligibility dates and review dates

Upon request by a victim, CSC and/or PBC may also disclose any of the following information, described in Sections 26(1)b-d) and 142(1) of the CCRA:

Information that CSC and PBC Can Disclose to Registered Victims CSC PBC
  • the offender's age
X X
  • the location of the penitentiary
X X
  • the name of the penitentiary where the offender is incarcerated
X  
  • the date of any PBC hearing for the purposes of a review under section 130 of the CCRA (detention)
X X
  • whether the offender is in custody and, if not, the reason
X X
  • where a person has been transferred from a penitentiary to a provincial correctional facility, and the name of the province in which the provincial correctional facility is located
X X
  • a summary of the reasons for the transfer and the name and location of the penitentiary in which the sentence is now being served
X  
  • if the offender is to be transferred to a minimum security institution, and it is possible to notify the victim before the transfer, a summary of the reasons for the transfer and the name and location of the institution in which the sentence is to be served
X  
  • the programs in which the offender is participating or has participated
X  
  • the serious disciplinary offences the offender has committed
X  
  • information about the offender's correctional plan, including information about the offender's progress towards meeting the objectives of the plan
X  
  • that the offender has been removed from Canada under the Immigration and Refugee Protection Act before the expiration of the sentence
X  
  • the date on which the offender is to be released on parole or statutory release
X X
  • the conditions1 attached to the offender's parole or statutory release
X X
  • the destination of the offender on parole or statutory release, and whether the offender will be in the vicinity of the victim while travelling to that destination
X X
  • the date on which the offender is to be released on unescorted absence
X X
  • the conditions1 attached to the offender's unescorted temporary absence
X X
  • the destination and the reasons for any unescorted temporary absence and whether the offender will be in the vicinity of the victim while travelling to that destination
X X
  • the date on which the offender is to be released on escorted temporary absence where the PBC has approved the absence as required by subsection 746.1(2) of the Criminal Code
  X
  • the date, if any, on which the offender is to be released on work release or escorted temporary absence that does not require approval from the PBC as required by subsection 746.1(2) of the Criminal Code
X  
  • the conditions1 attached to the offender's work release and escorted temporary absence
X  
  • the destination of the offender on work release and escorted temporary absence, and whether the offender will be in the vicinity of the victim while travelling to that destination
X  
  • the reasons for any escorted or unescorted temporary absence or work release
X  
  • dates, destination and reasons for travel permits
X  
  • whether the inmate's conditional release has been suspended
X  
  • access to a photograph of the offender taken for the following reasons:
    1. the release of the offender on unescorted temporary absence
    2. the offender's work release
    3. the offender's release on parole
    4. the offender's release by virtue of statutory release or the expiration of the sentence
  • any subsequent photograph of the offender taken by CSC before the end of the sentence
X  
  • Long-term supervision orders (start date, conditions, destination)
X X
  • Long-term supervision orders (expiry date)
X  
  • when an eligible offender did not apply for judicial review (reduction of parole ineligibility period) and the next date on which the offender can reapply
X  
  • whether or not the offender has appealed a decision of the PBC, as described under section 147 of the CCRA, and the outcome of that appeal
  X
  • the reason for a waiver of the right to a hearing, as described under subsection 140(1) of the CCRA, if the offender gives one
  X

1 When a victim has provided CSC and/or PBC with a statement in accordance with the Corrections and Conditional Release Act (CCRA), Section 133(3.1), if the releasing authority decides not to impose conditions under that subsection, it shall provide written reasons for the decision.

Instructions

Please ensure Parts A to C are completed

Under the Corrections and Conditional Release Act (CCRA), the Correctional Service of Canada (CSC) and the Parole Board of Canada (PBC) may provide people who apply to receive information as a victim with information about the offender who harmed them. Please complete this application form if you wish to receive information as a victim.

A guide to assist in the completing of this application is available on the CSC and PBC websites. To find out more about who is considered a victim under the Act, consult the CSC or PBC websites.

If you would like to provide additional information that is not related to the application, please discuss how to do this with CSC or PBC staff. You will find contact information at the end of this form.

Victim Information and Details

Name (print)

Date of birth (YYYY-MM-DD)

NOTE: You must be 18 years of age or older to apply to receive information about an offender. If you were harmed by an offender and you are under 18, a parent or guardian may apply to receive information about the offender on your behalf.

Name of the offender (print) who harmed you? Please identify if there was more than one offender involved.

Was the offender convicted of the act that harmed you?

Yes

No

Did you provide a victim impact statement for court?

Yes

No

Part A – Request to receive information as a victim

Please check the ONE statement that best suits your situation:

  1. I was harmed (suffered a loss or have been physically or emotionally hurt) as a result of a criminal offence.

    Please go to A1
  2. I am the spouse, common-law partner or relative of, or legally responsible for, the person who was harmed as a result of a criminal offence and that person is now deceased, ill, incapacitated or under the age of 18, or I am the guardian of the dependents of that person.

    Please go to A2
  3. I was harmed as a result of an act committed by an offender (whether or not the offender was prosecuted or convicted of that act) and a complaint was made to the police or the Crown attorney, or an information was laid under the Criminal Code, in respect to that act.
    Please go to A3

Privacy Notice Statement

The information you provide on this form is collected by CSC/PBC under the authority of the Corrections and Conditional Release Act (CCRA) for the purpose of determining your eligibility to receive information about an offender who harmed you. Missing personal information may result in your request being denied. You have the right to the correction of, access to, and protection of your personal information under the Privacy Act. Personal information collected through the processing of your application will be stored in the Personal Information Bank CSC PPU 135 and PBC PPU 015 and can be accessed and assessed for accuracy by sending a written request to the Director, Access to Information and Privacy, at either Correctional Service of Canada (340 Laurier Avenue West, Ottawa ON, K1A 0P9) or Parole Board of Canada (410 Laurier Ave West, Ottawa, ON K1A 0R1).

Please note that your personal contact information, such as your telephone number and address, will not be shared with the offender without your consent. For more information visit Info Source.

Please fill one section only (A1 or A2 or A3)

A1: I was harmed (suffered a loss or have been physically or emotionally hurt) as a result of a criminal offence.

Offence(s):

Please tell us about your connection to the offence. Check ONE of the following:

  1. The offence was committed against me.
  2. The offence was committed against someone with whom I have a close and direct relationship.

    Name of the person:

    My relationship to the person is:
  3. I have a connection to the offence (Describe how you are connected):

    In what province and city was the offender prosecuted? Please tell us the name of the court if you know it.

    Province:

    City:

    Court:

Please go to Part B

OR

A2: I am the spouse, common-law partner, relative of, or legally responsible for the person who was harmed and who is now deceased, ill, incapacitated, or under the age of 18, or am the guardian of the dependents of that person.

Please tell us about the person who was harmed as the result of the offence (who is now deceased, ill, incapacitated or under the age of 18):

Full Name

Date of Birth (YYYY-MM-DD)

My relationship to them - Are you the spouse, common-law partner, relative or guardian of the person harmed, or guardian of the dependants of the person harmed?

Offence(s):

In what province and city was the offender prosecuted? Please tell us the name of the court if you know it.

Province:

City:

Court:

Please go to Part B

OR

A3: I was harmed as a result of an act committed by an offender (whether or not the offender was prosecuted or convicted of that act) and a complaint was made to the police or the Crown attorney, or an information was laid under the Criminal Code, in respect to that act.

The law enables the CSC and PBC to provide information about an offender if you demonstrate that you meet the two criteria below from sections 26(3) and 142(3) of the Corrections and Conditional Release Act.

Harm was done to you, or you suffered physical or emotional damage, as a result of an act of an offender, whether or not the offender was prosecuted or convicted for that act,

and

A complaint was made to the police or a Crown attorney, or information was laid under the Criminal Code, in respect of that act.

I meet these two criteria.

  1. What was the act or offence that harmed you?
  2. What is your connection to the offence? (See examples in Section A.3.2 of the Instructions for Completing Application to Receive Information as a Victim)
  3. How were you affected by the offence? (See examples in Section A.3.3 of the Instructions for Completing Application to Receive Information as a Victim)

Name of Police Office / Crown Office where the complaint was made about the act(s):

Police/Crown File #:

Part B – Contact Information

Please tell us how you would like to receive information from CSC and PBC about the offender(s).

Mailing Address (Apt., Street, P.O. Box)

City/Town:

Province:

Postal Code:

Residential Address (if different than mailing address):

City/Town:

Email:

Home Phone:

Business Phone:

Cellular Phone:

Alternate Phone:

In what order should we call the above telephone numbers? Please number 1 through 4.

Home

Business

Cellular

Alternate

May we leave a message on your voice mail? (i.e. our name, phone number, organization and whether or not it is urgent)

Please answer Yes (Y) or No (N).

Home

Business

Cellular

Alternate

Can CSC and PBC leave a message if someone other than you answers the phone?

If yes, please provide the name(s) and relationship(s) to you.

YES

NO

Name(s)

Relationship(s) to you

Notification by an Agent (optional)

If you would like to name a person as an agent to receive information about the offender on your behalf, rather than receiving it directly, please provide the following information. *NOTE: If you complete this section, CSC and PBC will not contact you directly.

Agent's name or Name of Agency (print)

Agent's relation to you (mother, friend, lawyer, victim services, police, etc.)

Mailing Address (Apt., Street, P.O. Box)

City/Town

Province

Postal Code

Agent's Telephone Numbers and Email

Home

Business

Facsimile

Cellular

Alternate

Email:

Part C – Applicant's Signature (You must sign this form in order for CSC or PBC to register you as a victim).

To the best of my knowledge, I am a victim and/or a person harmed as per the definition or criteria in the Corrections and Conditional Release Act and the information provided by me in this application is true.

Signature

Date (YYYY-MM-DD)

Part D (optional) – Application to Receive Information as a Victim's Spouse/Common-Law Partner

Signature of Applicant's Spouse/Common-Law Partner (Your spouse or common-law partner must sign this form in order for CSC or PBC to register him or her as a victim).

To the best of my knowledge, I am also a victim and/or a person harmed as per the definition or criteria in the Corrections and Conditional Release Act and the information provided by me in this application is true. I have checked the box below that best matches my situation:

  1. I was harmed (suffered a loss or have been physically or emotionally hurt) as a result of a criminal offence.
  2. I am the spouse, common-law partner, or relative of, or legally responsible for, the person who was harmed as a result of a criminal offence and that person is now deceased, ill, incapacitated or under the age of 18, or I am the guardian of the dependents of that person.
  3. I am a person who was harmed as a result of an act committed by an offender (whether or not the offender was prosecuted or convicted of that act) and a complaint was made to the police or the Crown attorney, or information was laid under the Criminal Code, in respect to that
  • I meet these two criteria. (refer to section A3 on the second page)
  1. What was the act or offence that harmed you?
  2. What is your connection to the offence? (See examples in Part D of the Instructions for Completing Application to Receive Information as a Victim)
  3. How were you affected by the offence? (See examples in Part D of the Instructions for Completing Application to Receive Information as a Victim)

Once you have completed and signed the form, please send it to the office that you have been in contact with. If you have not been in contact with a PBC or CSC office, please send the completed form to the office nearest you. See list below.

For more information or to obtain an additional form, please visit CSC's website or PBC's website.

If you need assistance, please call any of the toll-free numbers listed below.

Parole Board Canada Correctional Service Canada
Address Victims' Information Lines Address Victims' Information Lines
PBC – Atlantic Region CSC – Atlantic Region
(New Brunswick, Nova Scotia, Prince Edward Island, Newfoundland and Labrador)
1045 Main Street, Unit 101
Moncton, New Brunswick
E1C 1H1
Toll-Free: 1-866-789-INFO (4636)
Fax #: 506-851-6926
1045 Main Street, 2nd Floor
Moncton, New Brunswick
E1C 1H1
Toll-Free: 1-866-806-2275-1-5
Fax #: 506-851-4684
PBC – Québec Region CSC – Québec Region
200 René Lévesque Blvd West
10th Floor, Suite 1001
Montréal, Québec
H2Z 1X4
Toll-Free: 1-877-333-4473
Fax #: 514-283-5484
3 Place Laval, 2nd Floor
Laval, Québec
H7N 1A2
Toll-Free: 1-866-806-2275-2-4
Fax#: 450-967-3774
PBC – Ontario/Nunavut Region CSC – Ontario Region
 (East of Thunder Bay and within the territory of Nunavut)
516 O'Connor Drive
Kingston, Ontario
K7P 1N3
Toll-Free: 1-800-518-8817
Fax #: 613-634-3862
443 Union Street West
P.O. Box 1174
Kingston, Ontario
K7L 4Y8
Toll-Free: 1-866-875-2225
Fax #: 613-536-4730
PBC – Prairies Region – Saskatoon Office
(Saskatchewan, Manitoba, NW Ontario)
CSC – Prairies Region
(Alberta, Saskatchewan, Manitoba, NWT, NW Ontario up to and including Thunder Bay)
101-22nd Street E., 6th Floor
Saskatoon, Saskatchewan
S7K 0E1
Toll-Free: 1-888-616-5277
Fax #: 306-975-5200
P.O. Box 9223
Saskatoon, Saskatchewan
S7K 3X5
Toll-Free: 1-877-322-5822
Fax #: 306-659-9314
PBC – Prairies Region – Edmonton Office
(Alberta and NWT)
 
Scotia Place, Scotia 2
Suite 401, 10060 Jasper Ave.
Edmonton, Alberta
T5J 3R8
Toll-Free: 1-800-597-4397
Fax #: 780-495-4403
 
PBC – Pacific Region
(British Columbia, Yukon)
CSC – Pacific Region
(British Columbia, Yukon)
1925 McCallum Road, 2nd Floor
Abbotsford, British Columbia
V2S 3N2
Toll-Free: 1-888-999-8828
Fax #: 604-870-2498
Unit 100 - 33991 Gladys Avenue
P.O. Box 4500
Abbotsford, British Columbia
V2S 2E8
Toll-Free: 1-866-806-2275-1-1
Fax #: 604-870-6152

To be Completed by the Correctional Service of Canada and/or Parole Board of Canada Only

Applicant Name:

Offender Name:

FPS/File Number:

  1. Is the name of the victim different now from the name at the time of the offence?
    Yes
    No

    If yes, provide the name at the time of the offence:
  2. Was harm suffered?  
    Yes
    No

    If yes, list the documents used to verify this:
  3. Was the offender convicted of the act that harmed the victim? 
     
    Yes
    No
    1. If yes, list the documents used to verify this:
    2. If no, was a complaint made to the Police/Crown or an information laid under the Criminal Code? (Record details regarding verification of the complaint made to Police/Crown or the information )
      Yes
      No

      Police / Crown File #:

      Name and position of the person who confirmed the complaint/information laid:

      Date (YYYY-MM-DD)
  4. Does this applicant meet the definition or criteria of a victim?  
    Yes
    No

    Section 2.1 of the CCRA

    Section 2.1(c) of the CCRA

    Section 2.1(a) of the CCRA

    Section 2.1(d) of the CCRA

    Section 2.1(b) of the CCRA

    Section 26(3)/142(3) of the CCRA
  5. If the applicant's spouse/common-law partner is also applying, does the spouse/common-law partner meet the definition or criteria of a victim? 
    Yes
    No

    Section 2.1 of the CCRA

    Section 2.1(c) of the CCRA

    Section 2.1(a) of the CCRA

    Section 2.1(d) of the CCRA

    Section 2.1(b) of the CCRA

    Section 26(3)/142(3) of the CCRA
  6. Rationale for decision:
  7. Name of Delegated Authority (CSC) (print)

    Position

    Signature

    Date (YYYY-MM-DD)
  8. Name of Delegated Authority (PBC) (print)

    Position

    Signature

    Date (YYYY-MM-DD)

Instructions for Completing the Application to Receive Information as a Victim Form Put Away on File

Name and Date of Birth

Provide your current legal name. If you have changed your name since the time of the commission of the offence that harmed you, you need to provide your previous name. Your date of birth is required to ensure that you are 18 years of age or older.

Name of the offender(s) who harmed you

If more than one offender harmed you, provide the names of all the offenders you are requesting information about.

Was/were the offender(s) convicted of the act that harmed you?

Check Yes or No based on your situation. If you do not know, leave this space blank.

I provided a victim impact statement for court

If you select YES we will check the offender's file to ensure we have a copy.

Please Ensure that Parts A to C are Completed.

If you require more space than what is provided on this application form, please use and include an additional piece of paper, with your signature and the date.

Part A – Request to receive information

CSC and PBC can provide certain information about offenders only to people who meet the definition of 'victim' (1 and 2) or meet other criteria (3) that appear in the Corrections and Conditional Release Act (CCRA). In this part, you will provide information that allows CSC and PBC to determine if you meet the definition or criteria.

You need to complete the one section that corresponds to your situation.

If you select (1) go to A1 of the application form.

If you select (2) go to A2 of the application form.

If you select (3) go to A3 of the application form.

A1) I was harmed (suffered a loss or have been physically or emotionally hurt) as a result of a criminal offence

This section allows people to request information about offenders who harmed them or harmed someone with whom they have a close and direct relationship, and allows people who were harmed by their connection with the offence to receive the information. Check the box in this section if one of these options applies to your situation and if the offender was convicted for the commission of the offence.

Offence(s)

Indicate all of the offences that harmed you and for which the offender was convicted, resulting in the current sentence. (Information about previous sentences, if applicable, is not required.).

Select one of the following (A, B or C). Select the option that applies to your situation.
  1. The offence was committed against me.
    Example: I am the person who was assaulted by the offender.
  2. The offence was committed against someone with whom I have a close and direct relationship. Name of the person. My relationship to the person is:
    Example 1: I am the husband of the woman who was assaulted by the offender.

    Example 2: I am the mother of the 5 year-old boy who was assaulted by the offender.
  3. I have a connection to the offence. (Indicate your connection)
    Example 1: I was in the bank while it was being robbed and was named in the police report.

    Example 2: I am the clerk who was working at the store when it was robbed and provided a victim impact statement to the court.
Name/Place of Court of Conviction

Provide the province and city (and name of the court, if you know it) where the offender (or each of the offenders) was convicted.

A2) I am a person who was harmed as a result of an offence against a person who is deceased, ill, incapacitated or under the age of 18.

This part allows people to request information about offenders who harmed someone who is unable to make the request him- or herself.

Example 1: My family member was killed by the offender.

Example 2: My mother was assaulted by the offender and is now mentally incapacitated.

Example 3: I am the guardian of children whose parents were killed by the offender.

Full name/Date of birth/My relationship to them

Provide the full name and date of birth (if known) of each of the persons who was harmed and is now deceased, ill or incapacitated, and state your relationship with each person. If you require more space than what is provided on this application form, please use and include an additional piece of paper, sign it and date it.

Offence(s)

Indicate all of the offences that harmed you and for which the offender was convicted.

Name/Place of Court of Conviction

Provide the province and city (and name of the court, if you know it) where the offender (or each of the offenders) was convicted.

A3) I was harmed as a result of an act committed by an offender (whether or not the offender was prosecuted or convicted of that act) and a complaint was made to the police or the Crown attorney, or an information was laid under the Criminal Code, in respect to that act.

This part allows people who meet certain criteria to receive information about an offender currently serving a federal sentence (of two years or more) even if the offender was not prosecuted or convicted for the act that harmed them, if they can demonstrate that they meet both criteria set out within Sections 26(3) and 142(3) of the Corrections and Conditional Release Act.

  1. that harm was done to you, or you suffered physical or emotional damage, as a result of an act of an offender, whether or not the offender was prosecuted or convicted for that act, and
  2. that a complaint was made to the police or a Crown attorney, or information was laid under the Criminal Code, in respect of that act.

If this reflects your type of situation check the box beside "I meet these criteria" and complete the 3 questions that follow:

  1. Name the "Act(s)/offence(s) committed".
  2. Examples of possible connections to offences:
    I was assaulted and laid a complaint, but the offender was not prosecuted for that act.
  3. Examples of how you were affected:
    I cannot sleep or work because of this offence.
    I am afraid to be alone/go out in public/be in a moving vehicle because of this offence.
    I am anxious/depressed/unable to concentrate because of this offence.

Provide the Name of Police Office / Crown Office where the complaint was made about the act(s) and Police/Crown File number.

Part B – Contact Information

Provide the information that will allow CSC and PBC to contact you. You may change your preferences at any time by contacting CSC or PBC and indicating the changes in writing or by phone.

Receiving notifications by telephone

Provide the phone numbers at which CSC and PBC can reach you and indicate in what order CSC or PBC should call the numbers. Additionally, if you would like messages to be left with anyone, please provide their name and relationship to you.

Receiving notifications by postal mail

Provide the complete mailing address to which CSC and PBC can mail the notifications. If your mailing address (e.g., P.O. Box 181) is different from your residential address (e.g., 947 Perth Road), please provide both addresses on your application form.

Receiving notification by an agent (optional)

If you would like CSC and PBC to provide you with notifications about this offender indirectly, through another person who will share the information with you, provide the name of the agent, your relationship to him or her, and his or her contact information. If you are including more than one phone number, indicate in what order CSC/PBC should call. When you choose this option CSC and PBC will not contact you directly, but you can always contact CSC or PBC yourself to obtain information or clarification.

Part C – Applicant's Signature

Once you have provided all of the required information on the form, you must sign it. By signing it you are indicating that:

  • all of the information you have provided on the form is true;
  • you have been harmed by the offender; and,
  • you believe you meet the definition of victim or criteria in the CCRA as explained on the form.

Part D – Signature of Applicant's Spouse/Common-law Partner

The applicant's spouse or common-law partner must sign the form if he or she would also like to receive notifications about the offender. By signing the form you are indicating that:

  • you were also harmed by the offender;
  • you believe you meet the definition of victim or the criteria in the CCRA that are quoted on the form; and
  • you would like to receive notifications on the basis of the same notification preferences indicated by your spouse or partner.
Check the statement (1, 2 or 3) that applies to your situation.
  1. I am a person to whom harm was done or who suffered physical or emotional damage as a result of the commission of an offence. OR
  2. I am a person who was harmed as a result of an offence against a person who is deceased, ill, incapacitated or under the age of 18. OR
  3. I am a person who was harmed as a result of an act of an offender (whether or not the offender was prosecuted or convicted of that act) and a complaint was made to police or the Crown attorney, or an information was laid under the Criminal Code, in respect to that act.

If you selected 3 then you must meet both of the following criteria:

  1. harm was done to you, or you suffered physical or emotional damage, as a result of an act of an offender, whether or not the offender was prosecuted or convicted for that act, and
  2. a complaint was made to the police or a Crown attorney, or an information was laid under the Criminal Code, in respect of that act.

If this reflects your type of situation check the box beside "I meet these criteria" and complete the 3 questions that follow:

  1. Name the "Act(s)/offence(s) committed".
  2. Examples of possible connections to offences:
    I was assaulted and laid a complaint, but the offender was not prosecuted for that act.
  3. Examples of how you were affected:
    I cannot sleep or work because of this offence.
    I am afraid to be alone/go out in public/be in a moving vehicle because of this offence.
    I am anxious/depressed/unable to concentrate because of this offence.

Once you have completed and signed the form, please send it to the office that you have been in contact with. If you have not been in contact with a PBC or CSC office, please send the completed form to the office nearest you. See list included in registration form.