Appeal of Victims' Rights Decision

Should you have any questions when completing this form, please call the Scheduling Co-ordinator at (204) 925-6116 (collect).

Fields marked with (*) are required.

Section A - Appeal Requested by

Claimant Name

Preferred Pronouns

Claim Number

Claimant Address

City/Town

Province

Postal Code

Phone (home)

Phone (cell)

Section B - Representative Information

Name of Representative

Address

City/Town

Postal Code

Phone

Fax

If you will be represented on your appeal, you must provide a separate signed and dated authorization naming your representative

Section C - Interpretation Services

Any required interpretation services will be arranged by the Appeal Commission.

Hearing provided in French

Interpreter service

Interpreter language

Section D - Accommodation

Accommodations are arrangements that allow persons of all abilities to participate fully in the appeal process. If you want to request an accommodation to participate in the appeal process at the Appeal Commission, please tell us about your accommodation needs. Provide as much information as you can so we can consider your request and respond.

Request for Accommodation

If you need help with the form or are unable to complete the form, please call us.

Section E - Decision Appeal Specifics

Decision Date

Decision(s) to Appeal

Reasons for Appeal

NOTE: If providing additional written evidence or submission, this must be sent to the Appeal Commission at least 5 business days prior to the hearing.

Section F - Method of Appeal

Please indicate how you want your appeal heard.Videoconference
Teleconference
In Office at 330 St. Mary Ave.
File Review

If hearing other than file review, state reasons

The Chief Appeal Commissioner has the final authority to determine the method of appeal.

Section G - Signature/Confirmation

Signature

Date