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AR 180/2004 VICTIMS RESTITUTION AND COMPENSATION PAYMENT FORMS REGULATION

(Consolidated up to 221/2013)

ALBERTA REGULATION 180/2004

Victims Restitution and Compensation
Payment Act

VICTIMS RESTITUTION AND COMPENSATION
PAYMENT FORMS REGULATION


Forms

1   A statement of property and revenue to be filed with the Court by an offender must be in Form 1.

AR 180/2004 s1;221/2013

Notice of objection

1.1   A notice of objection to be filed with the Minister under section 1.6 of the Act must be in Form 2.

AR 221/2013 s4

Expiry

2   For the purpose of ensuring that this Regulation is reviewed for ongoing relevancy and necessity, with the option that it may be repassed in its present or an amended form following a review, this Regulation expires on May 31, 2019.

AR 180/2004 s2;221/2013


Form 1

Statement of Property and Revenue

IN THE COURT OF QUEEN’S BENCH OF
THE PROVINCE OF ALBERTA

BETWEEN:

Her Majesty the Queen

- and -

[name of offender]

I,    [name of offender] _ of the ___________ of ___________ in the Province of Alberta, MAKE OATH AND SAY:

1.  THAT I am the offender in a restitution order made on the    (date)   ;

2.  THAT I have made a full and complete disclosure of my present financial situation in this Affidavit;

3.  THAT all the information contained in this Affidavit is true and accurate.

SWORN BEFORE ME at the _______ of            )
__________ in the Province of Alberta,                )
this ___ day of _______________, 20                  ) _______________
__________________________________           )
A Commissioner for Oaths in and for                   )

the Province of Alberta, or a Notary Public.          )

A       Debtor Information    (Please print)

Full Name                                       e‑mail Address                                    

Telephone No.                   Cell No.           Fax No.                  

Present Address:  Street Address                                                                

                              City                                                  Postal Code           

Birthdate             Social Insurance No.             Driver’s Licence No.         Alberta Health Care Insurance No.                         

B      Income  (If income is from self‑employment see section “C”)

Name of Current Employer                                                                           

Telephone No.                                   Fax No.                                               

Present Address:  Street Address                                                                  

                              City                                                   Postal Code           

Nature of Business                                 Position Occupied                          

Gross Monthly Wages or Salary $           Net Monthly Wages or Salary $    

Name of Previous Employer                                                                         

Telephone No.                                   Fax No.                                               

Present Address:  Street Address                                                                  

                              City                                                   Postal Code           

Nature of Business:                                 Position Occupied:                        

Gross Monthly Wages or Salary $           Net Monthly Wages or Salary $    

List your trade, profession or otherwise:

What is your annual bonus from your employer? $                                       

How much money do you receive from commission work? $                        

How much of a raise will you be receiving this year, and when? $                 

How much money do you receive from other part‑time employment? $        

How much money do you receive from income producing hobbies? $          

Add all other income (dividends, rental income, annuities, pensions, etc.) $  

Annual income tax and/or GST rebates $                                                       

* Any additional household income (spousal, roommate, etc.) $                   

TOTAL MONTHLY INCOME  $ __________

 

BANK ACCOUNTS, etc.     List of chequing and savings accounts, term deposits, registered savings plans, annuities, etc.

 

Type of Deposit

Name of
Institution

Account No.

Branch
Address

Amount

 

 

 

 

 

 

 

 

 

 

 

*OPTIONAL*
Provide tax records for last 3 years
Description                                                                                                     
Amount                                                                                                          

Sole Return                   YES                     NO

C      Income from Self‑employment

If the business is a proprietorship, partnership or joint venture, list the names, addresses and telephone numbers of any partners, principals or participants

Name                                                  
Address                                                      Telephone No.                    

Type of Business                                  Name of Business                             

Telephone No.                     Business location: street address                        

City                                Province                              Postal Code                 

 

Is this business a

proprietorship    joint venture    partnership     corporation 

What is the percentage of the Business owned by you?                                %

What is the net book value of the Business?  $                                               

What is the estimated market value of the Business? $                                   

 

Itemize your yearly income below:

Salary:                           Bonuses:                           Dividends:                           

Other (automobile allowances, expenses, etc.) (describe):                              

Itemize other benefits (company car, house, loans, savings plans, share purchase options, etc.) (describe):    

 

Total income:  $                      

 

Include a copy of the business financial statement.

 

If the business is a corporation, complete the following:

 Public           Private            Professional           Other (describe)

 

Are you an officer or a director?     Yes    No     Title:                         

 

If the business is NOT a public corporation, complete the following:

Total number of shares issued and outstanding
(describe type and class of shares):                                                                

Class                           Number                            Net book value                   

Total number of shares of each class held by you:                                         

Class                           Number                            Net book value                   

 

Total amount of all loans payable to you by the corporation:                         

Amount             Interest earned (if any)               Terms of repayment           

D      Monthly Expenses

1    Rent or Mortgage payments:                                                                     
(name Landlord or Mortgagee):                                                                

2    Property taxes                                                                                          

3    Utilities                                                                                                    

4    Groceries (food, toiletries, etc.)                                                                

5    Clothing                                                                                                   

6    Transportation (fuel, parking,
repairs, public transit, etc.)                                                                       

7    Personal expenses (prescription drugs,
medical and dental expenses, expenses
not covered by insurance, etc.)                                                                

8    Home or Rental Insurance                                                                        

9    Vehicle Insurance                                                                                    

10  Life Insurance                                                                                          

11  Disability Insurance, etc.                                                                          

12  Maintenance                                                                                             

13  Other (specify)                                                                                         

14  List your monthly payments (loans,
credit cards, personal debts, etc. below

Type of debt:                                              To whom payable:                       

Amount outstanding:                                 Monthly payment:                        

 

TOTAL MONTHLY EXPENSES:                   TOTAL EXPENSES:               

E       Assets

Real estate:  Fill in the required information below regarding all real estate (homes, rental properties, cottages, condominiums, etc.) inside and outside the Province of Alberta in which you own an interest.

Municipal address:                               Legal description:                              

Purchase price:                                     Balance owing:                                   

Current market value:                       

List the name and address of the mortgagee for
each property described above:                                                                      

 

Motor vehicles, etc.:   Fill in the requested information regarding all motor vehicles (cars, trucks, farm machinery, construction equipment, recreation vehicles, aircraft, etc.) in which you own an interest.

 

Type                                      Make model                                  Year            

Serial no.                      Purchase price                     Balance owing                

Current market value                               Equity                    

 

List of your shares, bonds, etc., and their current market value below:

 

Type                             Number                      

Dividends (if any)                             Current market value                        

F       Insurance

List all insurance policies in which you are a named beneficiary.  Include the insurance company granting the policy, the policy number, the amount, the person insured, the premium and its cash surrender value.

 

Insurance company                                      Policy no.                                  

Amount                              Person Insured                                                    

Premium                                     Cash surrender value                                   

 

List location of all certificates for all corporate holdings (both public and private) and the name(s) and address(es) of the Broker(s) through whom you deal.

 

Location of certificates:                     Name and address of Broker(s)            

 

List all properties or interests held by a trustee on your behalf.  Describe the asset being held, the location of the asset and the name and address of the Trustee.

 

Description of assets held:                          Location of assets                       

Name and address of trustee                                                                          

G      Parties Who Owe You Money

List all parties who owe you money, including legal settlements on pending lawsuits.

 

Name:                        Address:                     Reason for Debt:                       

Amount owing                     Status of court act, if any                                    

H      Inheritances

List all estates in which you are the beneficiary of an inheritance.

 

Deceased’s name                      Address                  Value of inheritance       

I        Other Assets

List the kind, value and location of other assets (whether solely or jointly owned below):

 

Type of Asset

Description

Sole Owner

Location

Value

 

 

YES   NO

 

 

-interests in other businesses

 

   

 

 

-promissory notes,  judgment debts

 

   

 

 

-loans and mortgages receivable

 

   

 

 

-pension plans, registered pension plans, self- administered pension plans, life insurance policies, (cash surrender value)

 

   

 

 

 

   

 

 

-objects of art, jewellery, bullion, coins, cameras

 

   

 

 

-household furnishings and appliances (stereos, TVs, computers, crystal, dishwashers, etc.)

 

   

 

 

 

   

 

 

-other assets not previously listed

 

   

 

 

J       Transfer of Property

Have you given away, sold, assigned or otherwise transferred any property (land, buildings, vehicles, money, household furnishings, etc.) to anyone within the last 12 months?  Give details.

 

Description of Property

To Whom Transferred

Date of Transfer

How much money (if any) was received by you

 

 

 

 

 

 

 

 

 

NOTICE TO OFFENDER
TO:      (name of offender)   
Court File No.:                   

TAKE NOTICE THAT you are hereby required to provide to the Court a full and complete statement of your financial situation by completing this form.

Section 30 of the Victims Restitution and Compensation Payment Act states:

30(1)  A person is guilty of an offence if that person

                                 (a)    fails to comply with a restitution assistance order or a restitution payment order,

                                 (b)    subject to the directions of the Court, fails to provide a property and revenue statement, or

                                 (c)    subject to the directions of the Court, fails to attend a restitution assistance hearing as required pursuant to section 24.

(2)  A person who is guilty of an offence under subsection (1) is liable

                                 (a)    to a fine that is not greater than double the amount set out in the restitution order, or

                                 (b)    to imprisonment for not more than 6 months,

or to both a fine and imprisonment.

Form 2
Notice of Objection

I, (name), (occupation), of (name of city/town/district) in the (province/state) of ___________, and in relation to Civil Forfeiture Office (CFO) File Number _______ (on Notice of Disposition), MAKE OATH AND SAY THAT:

(Select all that apply by placing an “x” in the appropriate box and provide all requested information related to B or C):

1.  I have the following interest in the subject property identified in section 2:

                                     A.  Ownership

                □     B.  Rights of Possession.  Owner’s name and address is: ________

                □     C.  Other (specify nature of interest in space below)
_________________________________________

2.  The subject property is as follows:_________________________________

3.  The origin, nature and extent of my interest in the subject property is as follows: 

(List origin, nature and extent - for example, with respect to a claim to cash, explain who or what it came from, the nature of the transaction the cash was derived from and the purpose for it being in your possession. If more space is needed, add additional sheets.)  _________________________________________________

4.  I dispute disposition and forfeiture of the subject property for the following reason(s): ______________________________________________________

5.  My/Our address for service of documents is ________________________

SWORN/AFFIRMED BEFORE ME at       )
the_____of__________ in the Province  )
of Alberta, this ___ day of ______, 20                  )  ______________________
________________________________ )
A Commissioner for Oaths in and for the )
Province of Alberta, or a Notary Public.   )

AR 221/2013 s6