Government of Ontario: Ministry of the Attorney General

Ontario Victim Services Secretariat

Vulnerable Victims and Family Fund Request

Please return the completed form to the Victim/Witness Assistance Program Office, Ontario Victim Services Secretariat, in the attached postage-paid addressed envelope.

Please refer to the Vulnerable Victims and Family Fund Information Sheet for more details about this program.

Main Applicant's Personal Information

Last Name
First Name
Initial
Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code
Home Phone No. (incl. area code)
Alternate Phone No. (incl. area code)

I am a: (Please check one)

Adult victim Family member of a deceased victim Parent/caregiver of a child victim

Court Information

Name of Accused

Court Location

Service Request

Travel – Complete Section A Interpreter – Complete Section B Special Accommodations – Complete Section C

A. Travel

Travel from (Location)
To Court Location

Travel Dates
From (yyyy/mm/dd) Travel Dates To (yyyy/mm/dd)

Mode of Travel (please check all that apply):

Private Vehicle
Airplane
Bus
Train
Taxi
Rental Car
Other Other - Specify

Number of Hotel Nights Accommodation: Number of Hotel Nights Accommodation From – Date (yyyy/mm/dd) Number of Hotel Nights Accommodation To – Date (yyyy/mm/dd)

*If Applicable, I require help to cover the costs(s) of:
(only if there is no other person in applicant’s home
to perform the duty)

childcare dependant adult care

To enter additional travel dates, please use form 0319A-E.

B. Interpretation

Dates Required: From – Date (yyyy/mm/dd) Dates Required: To Date (yyyy/mm/dd)

Language Requested

C. Special Accommodations

Dates Required
From (yyyy/mm/dd) Dates Required To (yyyy/mm/dd)

Type of Service Required (please check all that apply):

Real Time Caption
Phonic Ear
Support Person
Specialized Equipment - Specialized Equipment Type

Other Accommodation (not listed above):
Please Specify

D. Notice of Collection of Personal Information (Please Read Carefully)

Personal information contained in or required by this form will be collected and used by the Ministry of the Attorney General, Ontario Victim Services Secretariat and their authorized representatives, to administer the Vulnerable Victims and Family Fund Program, including processing and assessing the information provided as well as making arrangements for eligible applicants to receive the services specified in the Fund. Please be advised that the staff administering the Vulnerable Victims and Family Fund Program may contact the signatory for the purpose of completing or clarifying information on this application form.

Personal information is being collected for the proper administration of a lawful activity authorized under section 5(4) of the Victims' Bill of Rights and section 5 of the Ministry of the Attorney General Act. If you have any questions about the collection and use of your information, please contact the Victim/Witness Assistance Program Coordinator at 1 866 320-3350.

E. Declaration and Consent (Please Read Carefully)

I hereby consent to the collection and sharing of the information provided in this application for the administration of the Vulnerable Victims and Family Fund Program and for making the related travel and accommodation arrangements on behalf of approved applicants. I understand that, except as required by law, personal information will be disclosed only for the purposes of administering the Program, as described above, or to third parties solely for the purpose of pre-booking travel and accommodation.

I hereby declare that I have no other recourse or financial resource to address this need.
I hereby declare that I understand the contents of the application and, to the best of my information and belief, all of my answers are true, correct and complete.
I hereby agree that, if I am approved for the program, I will follow the program restrictions and understand that expense coverage will be in keeping with rates established by the Ontario government. I further agree to return any unused advanced tickets if court proceedings are cancelled or postponed prior to travel.

Signature of Main Applicant

Signature of Main Applicant Date (yyyy/mm/dd)

FOR INTERNAL USE ONLY

Recommend Not Recommend

Signature

V/WAP Office Location
Date (yyyy/mm/dd)

Approved:

Yes No

Signature

V/WAP Office Location
Date (yyyy/mm/dd)

Supplementary Vulnerable Victims and family fund Request

Please complete the applicable sections below if:

You are a family member of the main applicant and you are also applying for one of the services available under the Vulnerable Victims and Family Fund.

OR
You are required to accompany an applicant as a support person (for persons who have a disability)

F. Additional Applicants

Applicant No. 2

Last Name
First Name
Initial

Mailing Address (if different from main applicant)

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

Home Phone No. (incl. area code)
Alternate Phone No. (incl. area code)

I am a: (Please check one)

Adult victim Child victim Family member of a deceased victim Parent/caregiver of a child victim

I require the following Service:

Travel - Travel please specify type:
Travel Dates Required (yyyy/mm/dd)
From: Travel Dates Required (yyyy/mm/dd) To:
Interpreter - Interpreter please specify language:
Interpreter Dates Required (yyyy/mm/dd)
From: Interpreter Dates Required (yyyy/mm/dd) To:
Special Accommodation - Special Accommodation please specify type:
Special Accommodation Dates Required (yyyy/mm/dd)
From: Special Accommodation Dates Required (yyyy/mm/dd) To:
*If you are applying for a support person, please fill out Section G

Applicant No. 3

Last Name
First Name
Initial

Mailing Address (if different from main applicant)

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

Home Phone No. (incl. area code)
Alternate Phone No. (incl. area code)

I am a: (Please check one)

Adult victim Child victim Family member of a deceased victim Parent/caregiver of a child victim

I require the following Service:

Applicant No. 4

Last Name
First Name
Initial

Mailing Address (if different from main applicant)

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

Home Phone No. (incl. area code)
Alternate Phone No. (incl. area code)

I am a: (Please check one)

Adult victim Child victim Family member of a deceased victim Parent/caregiver of a child victim

I require the following Service:

G. Support Person for Person with a Disability

Last Name
First Name
Initial

Mailing Address (if different from main applicant)

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

Home Phone No. (incl. area code)
Alternate Phone No. (incl. area code)

H. Notice of Collection of Personal Information (Please Read Carefully)

I. Declaration and Consent (Please Read Carefully)

I hereby consent to the collection and sharing of the information provided in this application for the administration of the Vulnerable Victims and Family Fund Program and for making the related arrangements on behalf of approved applicants.
I understand that, except as required by law, personal information will be disclosed only for the purposes of administering the Program, as described above, or to third parties solely for the purpose of pre-booking travel and accommodation.
I hereby declare that I have no other recourse or financial resource to address this need.
I hereby declare that I will not be receiving financial assistance that duplicates this request from any other sources.
I hereby declare that I understand the contents of the application and, to the best of my information and belief, all of my answers are true, correct and complete.
I hereby agree that, if I am approved for the program, I will follow the program restrictions and understand that expense coverage will be in keeping with rates established by the Ontario government. I further agree to return any unused advanced tickets if the court proceeding is cancelled or postponed prior to travel.

Signature of Applicant No. 2 or Parent/Guardian for Applicant under 16 years of age

Signature of Applicant No. 2 or Parent/Guardian for Applicant under 16 years of age Date (yyyy/mm/dd)

Signature of Applicant No. 3 or Parent/Guardian for Applicant under 16 years of age

Signature of Applicant No. 3 or Parent/Guardian for Applicant under 16 years of age Date (yyyy/mm/dd)

Signature of Applicant No. 4 or Parent/Guardian for Applicant under 16 years of age

Signature of Applicant No. 4 or Parent/Guardian for Applicant under 16 years of age Date (yyyy/mm/dd)

Signature of Support Person

Signature of Support Person Date (yyyy/mm/dd)