VICTIM's NAME: VICTIM IMPACT STATEMENT DECLARATION DE LA VICTIME SUPERIOR/ONTARIO* COURT OF JUSTICE (COUR SURERIEURE DE JUSTICE/DE JUSTICE DE LONTARIO™ cannon Fm Fame 242 PROVINCE OF ONTARIO ‘Subssetn 722 othe Gal Coe PROUNGE OF LONTARIO ‘Pearapte 221 dCs cine “SouthwestRegion Osi7 (esen ) Carer TF are Court Lozation: 415 Hunter Street, Woodstock Ontario Adresse ou tbuinal Inthe matter of Rv. Dans taffare de: Fo Vietimiuriter's name: ‘Nom de la vitima/ty eéclarant This form may be used to provide a description of the physical or emotional harm, property damage or economic loss suffered by you as the result of the commission of an offence, as well as a description of the impact ofthe offence on you. You may attach additional pages if you need more space. La présente formule peut étre utiisée pour présanter une description des dommages—matériels, corporels ou moraux—ou des partes économiques qui vous ont été causés par suite de la perpétration dlune infraction ainsi que des répercussions que linfraction a eues sur vous, Vous pouvez ajouter des pages addlitionnelles au besoin. ‘Your statement must not include: La déclaration ne peut comporter : any statement about the offence or the offender that isnot relevant to the harm or loss you suffered; de propos concemant finfraction ou fe délinquant qui ne sont pas pertinents au regard des dommages ou pertes que vous avez subis; any unproven allegations; dallégations non fondées; any comments about any offence for which the offender was not convicted: do commentaires sur des infractions pour lesquelles le détinquant n’a pas &t6 condamné; any complaint about any individual, other than the offender, who was involved in the investigation or prosecution ofthe offence; or de plaintes au sujet d'un’ particulier, autre que fe délinquant, qui était associé & Fenquéte ou a la poursuite de Vnaction; except with the court's approval, an opinion or recommendation about the sentence. sauf avec la permission du tribunal, de points de vue ou de recommandations au sujet de fa peine. You may present a detalled account of the impact the offence has had on your life. The following sections are examples of information you may wish to include in your statement. You are not required to include all of this information. Vous pouvez présenter un compte rendu détails des répercussions de Infraction sur votre vie. Les sections cfaprés ne constituent que des exemples de renseignements que vous pouvez inclure dans votre déclaration. Vous n’étes pas obligé dinclure tous ces renseignements, 1 te raped Roars qin sige pat $0" oy Page taeEmotional Impact Répercussions d'ordre émotif Describe how the offence has alfected you emotionally. For example, think of Vouillez dri les repercussions dardre émotif que Fivraction a eves sur vous, par exemple, en ce qui conceme + your ifestyle and activities; Votre made de vie et vos acts; + yourreatonships wth ethers such as your spouse femiy an fends {os elatons avec ls autos, notammant vate époux ou épouse, voto faite ot os ais; your ability to work, altend school or study; and ratte capac & travail, 6 réquentar 'école ou 8 étudior + yourfeelings, emotions and reactions 2s they relat to the offence tos sentiments, vos émotians ef vas réactions& Fgar de Fifraction Grancaters Statement Points | stil eamember the day it happened. My mother was siting onthe edge of her bed with tears running down her face. | asked her what happened, but al she said was, "Papais no longer with us Adam." | was very young but stil understood the concept of death and accepting gods plan fo us. Lite {id | know this was not my grandfathers time and someone had decided otherwise. Another person {decided his ime was up, a decision that shouldbe only be left to God hime, My younger brother Evan and | always had a unique bond with our grandfather, since wo are the youngest ofthe grandchikrn. This connection surpassed conversation, there was always a deep sense ‘of comfort bing inthe same room as my grandtather, he didn't even need to speak. When we visited fur grandparents house, which was quite often, Evan and | would watch cartoons with him alot. Even i he was in the midele of watching somethin else, my grandmother would put on Ytv and my grandfather ‘wouldnt think twice about his channel being changed, After my grandfather passed away it was hard for everyone. | was old enough to know that ‘Would never see him again but did not quite understand the tragic cause of his passing, My brother has {down syndrome and to him losing our Grandiather meant no longer watching cartoons on Saturday with cour grandparents. think the harct part ofall w ‘extremely close and the effect it had on her mood was very saddening and contagious when it came to ‘mys and especialy Evan ‘Alter witnessing my grandmothers stoke in 2008, | prayed all would be well inthe coming years, but 5 years lator also witnessed my grandfather be taken from my grandmother and l was devastated tohave lost a grandparent at al, let alone in such a manner 'As of Sunday, November 20th 2016 my grandmother is no longer with us. Iwas in her room the right of her peaceful passing and | wil always have a sense of calm knowing she passed being surround ‘2esing the citference in my grandmother, Her and | were by the ones she love. only wish | could say the same for my grandtather Today, my litle brother and| sil think of eur papa. When we see his tools inthe workshop or his ‘organ in our living room. I will alvaye wish Iad another opportunity to hear him play. so72 ger. or) ¢50 rae+o Physical Impact Répercussions d'ordre physique Describe how the offence has affected you physicaly, For example, thnk of Vouilez déarre les répereussions Sore physique que infraction & cuss sur vous, par axemple, once qui concemme ‘ongoing physical pain, discomfort, ness, scaring, disfigurement or physical limitation, | fa douleur physique persistant, linconfort, les maladies, Jes cicalrices, to défigurement ou Jes restrictions physiques; hospitalization or surgery you have had because ofthe offence; tune hospitalisation ou des interventions chizurgicales que vous aver dO subiren raison de Pnfrction; treatment, physiotherapy o medication you have been proscribed; [as tratoments, la physiothérapie ou les mécicaments qui vous ont ét presents; the need for any futher treatment or the expectation that you will ecsive further treatment; and Jes tailements supplémontaires cont vous aure2 besoin cu que vous vous atfendoz & recevot; ‘any permanent or long-term disability lune invite permanente ou de fangue durée. 80722) 18) Preeaatlee7ee Economic Impact Répercussions d’ordre économique Describe how the offence has affected you financially. For example, think of Veuillez décrire les repercussions dordre économiua que Finfractin @ oues sur vous, par exemple, on co qui concome the value of any property that was lost or damaged and the cost of repairs or replacement, Ja valour des bions pordus ou détuts et le codt de réparation cu de remplacement de cas biens; + any financial loss due to missed tim from work; les perles fnanciéres impulables 8 Fabsence do traval the cost of any medical expenses, therapy or counseling les dépensas médivales oo call de la thérapie et du counseling: ‘any costs or losses thal are hot covered by insurance. Jes coos, pertes ou dépenses qui ne sant pas couverts par fassurance, Please note that this Is nat an application for compensation or restitution Veuillez noter que la présente déclaration ne constitue pas une demande d'Indemnisation ou do dédommagement. 80722 en. 079) 650__ fears for secur Sraintes concernant eset any fears you have for your sec Rec json toute rain que vous BVEz POU respect to contact wih he offender: a lacs av Te delinguan ertet between te offender and membre YOU Contr gos contacts entre fe daquant et tla sécurité ty ort of your ay an nd, For ME famille et de vos amis, Par ‘exemple yotre sécurité ou cefio do vole concerns with SBe préoccupations concernant des 2 concems with respect 19 (das preoccupations con or close frends. Ga ems do vor frie ou do ais rece pestle es0720 bn Ten 80Drawing, poem or lettor(atech a separate page i needes) Dessin, podme, lettre Goiare une page aditionnale ay besoin) You may use this space o craw picture or wit a asm o tr il help you exprace the impact thatthe offence hes had on you Vous pouvez utiliser cet espace pour faire un dessin ou écrire un podme ou une letra si cola peu! vous aera dépalndre les repercussions que infraction a eues sur vous. | = like to presentiread my statement in court. \Faimerats présenterlire ma declaration devant fe ibunol ‘To the best of my knowledge, th information contained in this statement is trus ‘Ama connaissance, les renseignements contenus dans fa présonte déclaration sont exacts, pate this of aay ot Tame 2017, rater a at _Takont0,, Dvrhia® 8 aay eg aaiea inate Woe ae or ara eam Roam Siccor -Vuwute eae pein 5.722. 75} ¢80 [please print) Papesetl 7If you completed this statemant on behalf of the victim, please Indicate the reasore why you did so and the nature of your telationship withthe victim, Si vous avez rempl a présente déclaration au nom do la vietine, voulez idiquerfes raisons pour lesquelles vous Javez fit ans! que la nature de votre relat IF you are nat the person against whom the offence was comimilied but are completing this form on your own behalf, please indicate your relationship with the victim, 'S) vous nétes pas la personne contre qunvraction @ lé commice, mals que vous remplissee la présent farmulaie pour votre ez indiquer vote len avec fa victine. oanatn [Aine JUNE Ke at wel Yarrome: ADAM Siccae “Jan YK Vie a [please print