How to complete the form - IVAC - Accueil

1 Application for benefitsFor adult victims of crime (age 18 or over)How to complete the formTo help you correctly fill out this form , the Direction de l IVAC has made the publication IVAC COMPENSATION APPLICATION GUIDE For Adult Victims of crime (age 18 or over) available on its Website; this document provides the information you should have in hand before submitting an application. It will help you complete the form and determine which documents must be attached NOTE: If you were the victim of more than one crime (committed by different assailants), please file a separate application for you need additional help completing the application, please contact a crime victims assistance centre (CAVAC), a sexual-assault centre (CALACS), or an integrated university health and social-services centre (CIUSSS).

2 Their contact information for your area can be found can apply for benefits? any victim aged 18 or over who has been injured as the result of a crime occurring in Quebec covered by the Schedule to the crime Victims Compensation Act; or a claimant who is submitting an application on behalf of the victim, if the latter is deceased as the result of a crime occurring in Quebec covered by the Schedule to the crime Victims Compensation Act, or who is who has sustained material damage because he or she intervened to assist a peace officer making an arrest or prevent the commission of an offence is also considered a victim, even if that person was not killed or injured. If, in similar circumstances, he or she was injured or killed, that person is considered a November 24, 2016, the parent of a child murdered by the other parent has been recognized as a victim under the crime Victims Compensation Act.

3 The main criterion here is that the actual intent behind such an act is to harm the other parent. Consequently, the murder itself is sufficient to consider the other parent a victim; no additional proof is required in examining the eligibility of the NOTE: For crimes committed before November 24, 2016, victims covered by this new directive (in effect since November 24, 2016) may file an application for benefits even if the crime occurred more than two years previously. For crimes committed after that date, the two-year deadline for applications applies, as stipulated by crime victim, or, if that individual was killed, his or her dependents, is entitled to take advantage of the benefits provided for under the crime Victims Compensation cases: In certain cases, the victim is injured or killed ( , in a work or traffic accident) in circumstances that give rise to benefits for the victim or the latter s dependents provided under other legislation.

4 In such a situation, the victim may have to contact the CNESST (work accident) or SAAQ (traffic accident) 2 1 2 - A (2018-01)When must the application be filed?To take advantage of the benefits provided by the crime Victims Compensation Act, all applications must reach Direction de l IVAC no more than two years after the injury, material damage, or death in question. That period is one year for crimes committed prior to May 23, you have not filed an application for benefits within these timelines, you must complete Appendix 4 of this documents must be attached to an application for benefits?When filing an application for benefits, you must attach objective proof of injury.

5 If you possess a document issued by a member of a professional order or healthcare institution stipulating the injury caused by the crime , you must attach it to the application. By way of illustration, such a document could be a medical report or a psychological or psychosocial assessment. A list of documents accepted as objective proof of injury is available on the Direction de l IVAC s other documents requested are needed to expedite the processing of your application, and will be used to calculate any benefits you information must be provided?If the Direction de l IVAC is to open a file for you, several essential details must be included in your application; if any are missing, it will be returned.

6 Accordingly, you must provide information on the victim s identity, health-insurance number, and social-insurance number, as well as the date of the crime (whether a single event or events occurring over a period of time). You must also sign the notice of election (Section 13) and declare the information provided is true and complete by signing Section submitting your application, make sure to keep a copy for your send the completed and signed application for benefits, accompanied by all required documents, to the following address:Direction de l indemnisation des victimes d actes criminels1199, rue De Box 6056, Centre-Ville BranchMontr al (Qu bec) H3C 4E1 For any further information, please contact us at: Montr al area: 514 906-3019 Toll free (Canada only): 1 800 561-4822E-mail.

7 Of documents that might be requiredTo speed up the processing of your file, we strongly advise you to attach all required documents, as well as any others that might support and authenticate your application. The Direction de l IVAC may contact you to request any other documents deemed the box if the document has been attached to the applicationDocumentscAttestation of school attendancecMedical certificatecCNESST Medical certificatecNotice of assessment for year prior to crime or disabilitycCopy of dependents birth certificates that include the names of the mother and fathercCopy of death certificatecCopy of marriage or civil-union certificatecProvincial or federal income-tax return for year prior to crime or disabilitycJob-termination lettercDental and panoramic-radiography plancPsychological-assessment reportcPsychosocial-assessment reportcPolice reportcMedical

8 ReportcOriginal receipt for transportation of remainscOriginal receipt for crime -scene cleanupcOriginal receipt for payment of funeral expensescOriginal receipt or invoice for ambulance servicecReceipt for personal home carecEmployment-insurance slipcR3 or T5 slipcSubmission for spectacles, prostheses, or orthoticscSubmissions for routine home maintenancecPay stubs for past 12 months or letter from employercOther official document attesting to income (specify):cOther document (specify):Application for benefitsAdult victims of crime2 1 2 - A (2018-01)Page 1 of 4 File for Direction de l IVAC useAddress of domicile (the location where you live most of the time)FMIndicate in what capacity you are submitting an application for who paid for funeral, transportation of remains, or crime -scene cleanup in private residenceGuardian of a dependentDependent of deceased victim (see definition in Appendix 3)Close relation of deceased victim (see definition in Appendix 2 to determine if you are entitled to assistance)Other specify.

9 _____2 - Claimant (To be completed only if victim is disabled or deceased)NumberStreetClaimant s mailing address (if different from that of victim)ApartmentLanguage of correspondenceFrenchEnglishClaimant s last and first BoxMunicipalityProvince/StateCountryPost alcodeTelephone (home)Telephone (office)Telephone (alternate)Guardian of disabled individualOther specify: _____Country3 - CrimeDescribe the circumstances surrounding the crime , using extra sheets, if occurring over period of time:OREnd date: HHM MStart date:Location, city and/or addressProvince1 - Identification of victimSurname (as shown on birth certificate) BoxMunicipalityProvince/StateCountryPost al codeFirst namePresent surname (if different from above)Health Insurance Insurance of correspondenceFrenchEnglishCurrently with foster familyName of person in charge of foster familyTelephone If applicable, enter date of victim s death.

10 Attach copy of death of birthTelephone (home)Telephone (office)Telephone (alternate)Y Y Y Y M M D DY Y Y Y M M D DY Y Y Y M M D DY Y Y Y M M D DY Y Y Y M M D DIf the victim is deceased, please go to Section 6 and complete Appendix 2 Assistance for deceased victim s close relations and/or Appendix 3 Victim s - Bodily or psychological injuries Describe the bodily or psychological injuries sustained as a result of the crime :2 1 2 - A (2018-01)Page 2 of 4 Please attach a CNESST medical certificate ( attestation m dicale ) or any other document confirming the existence of an injury (see the IVAC Compensation Application Guide).An application for benefits must be submitted within two years of the date on which the victim sustained bodily injuries or material damage or died.