APPLICATION FOR FINANCIAL ASSISTANCE FOR VICTIMS TO ATTEND NATIONAL PAROLE BOARD HEARINGS

Name of Registered Victim: John Smith

PAYMENT

Address for mailing of information and cheque Note: You do not have to provide your personal address
123 Main St., Sherbrooke, Quebec, J1E 2T9

Cheque payable to:
John Smith

Fax No.
(819) 321-4567

Tel. No. (home)
(819) 321-4567

Tel. No. (office)
(819) 321-4567

Cell Phone
(819) 321-4567

E-mail
jsmithxyz@emailaddress.com

Alternate Contact
Mary Smith

Can Messages be left
Yes No

HEARING

Name of Offender
John Jones

Anticipated Date or Month (Y/M/D) of NPB hearing (if known)*
2007/02 - day unknown

Have you applied to NPB to attend a hearing?  
Yes No

Date of Application (Y/M/D)
2006/06/01

Have you been approved to attend?
Yes No

Is this the 1st application
for financial assistance? 
Yes No

If not, indicate date (Y/M/D) of previous application?
2006/07/15

Amount Received
$980

Has the NPB hearing been postponed? Yes No

If so, from what date (Y/M/D)?
2006/09/27

TRANSPORTATION

Proposed mode and Route of travel (plane, train, car) (If travelling by car, please indicate the approximate distance)
Car (Sherbrooke/Montreal/Sherbrooke) - 118km
Plane - Montreal/Kingston/Montreal

Anticipated Travel Expenses

Plane
$547

Train
n/a

Ground Transportation taxis/shuttle - $60

Car (kms) 118km

Parking Fees
$45

Airport Fees
n/a

Hotel (generally for 2 nights) or Private Accommodation $90 x 2 nights = $180

Meals & incidentals
3 days x $75 = $225

* An amended form should be submitted when the date is confirmed.

NOTE: Air or train fares are for economy or coach. Government of Canada Travel guidelines establish maximum amounts for meals,
with a daily allowance, including incidentals (e.g. telephone calls, tips) of approximately $75.

For assistance call 1-866-544-1007.