Government of Canada / Gouvernement du Canada
Symbol of the Government of Canada

Search

Criminal Code (R.S.C., 1985, c. C-46)

Full Document:  

Act current to 2024-11-11 and last amended on 2024-09-18. Previous Versions

FORM 34.1(Subsection 737.1(4))Statement on Restitution

Canada,

Province of blank line,

(territorial division).

To the court that is sentencing (name the offender) who was convicted, or was discharged under section 730 of the Criminal Code, of an offence under that Act.

I, (name of declarant), declare that (check the appropriate box):

  • [ ] (i) 
    I am not seeking restitution for the losses and damages I suffered as the result of the commission of the offence.
  • [ ] (ii) 
    I am seeking restitution in the amount of $blank line for the following losses and damages I suffered as the result of the commission of the offence.

I declare that I have suffered the following losses and damages as the result of the commission of the offence:

(Complete the following table if seeking restitution.)

Description

(describe each loss and damage)

Amount of loss and damage

(state the amount of each loss and damage)

1. blank line

blank line

2. blank line

blank line

3. blank line

blank line

4. blank line

blank line

I understand that the amount of my losses and damages must be readily ascertainable by the court. For that purpose, I am responsible for providing the court with all necessary documents, including bills, receipts and estimates, in support of my claim for restitution.

Dated this blank line day of blank line 20blank line, at blank line .

Signature of declarant

  • 2011, c. 6, s. 5
  • 2015, c. 13, s. 35
 

Date modified: