THIS FORM SHOULD BE USED BY: primary and secondary victims claiming statutory compensation

• primary victims claiming prescribed expenses under the Victims Assistance·Scheme (VAS)

Note: If you are claiming both compensation and prescribed expenses you only need to oomplete /he aile application form.

PART 1: Type of application

PART 2; Details of the victim applying for compensation and/or expenses

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RlDALTI ()

PART 3: Additional information for statistical and planning purposes

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IND.R-001739.PS.0015_R

2 Application for Compensation andlor Expenses

PART 4: Detai ls of person applying on behalf of the victim (if applicable) ~.~!;~~':-'7.~-:-:-;r:'-., -, ·,:,;~n . " .' :- 1':."';-::-:-::----: '7:'.~·..-..-.,~--:-~;_7.·~·-~:''!' .... ~_::_-c~~-· -. -'" -;:-'-:'7~:'-'.-'r':"'"''''''-. - .- , ./fthe;iliclilri is unable to 'complete the aRplication due to.incapacity.or.is under .1B years of age,:8 persoii.willJ 8 genuine ' ~:"·'· •. ir""~·:\\\ ' ··:!:·;:::.'·'. · H\~"-":'·"'}:':", :...(.':'.;"~:' .. \, :",,';·-i.f: " "'·: "',' ,,, ." ,,\:~""'., ... : ._~ •..• ; •... ::~ .. "'/".:' ~ .. ~ . ,_ \ ...... \· .. ,10:·.': .. ··.· ...... . .' . ~ mterest in II/e-welfare of the vlcllm./n8Y 'apply 01) IIJeir.behalf. , .. . :, .... , "":.~' ~ .. : .:. '!', ;-. " .~' ~ . i::'· .. ·::·:: . .'· . . ) .'::;' .. , .. ~:.: ' .. -" . . <.'" • ' .. ,

·~t~!~!J~;i;~!f ·:'~;f?~~0~~~~~~~~!~t<:~~:..~~:~;~~:~~- " ~~~:~ •. " ' --~.-= .. ;:,~,~~~;:::~:=~;~=~=:~;.~~~;~~j. ! <-;: ',,:;.~\ '~\ ;"""":.~'-;. : ... :'. ";FlfsV0,iviln :I)ilr:ne.· . Ot~er.\~ames I

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16. Your relationshIp to ·the 'v.lctim·': : :. ~' '~' " :.;::",:,,~ ,":;'.:. ;, ~'.:~:.:' .. : : , .,::}. :~. ,', .•. ~"~~'.: ,':: .. <, ..•.. : ::-:8. __ -- ----.... --"":--.... - .- - -.. -:--:-~ •. ~ ... '" : ~ ,~ , .~:~~::--.-"--:-- . I

17 . .why ;are. y",.~ 'actlng 011 behalf of the vIctim? ' ...... : .. ' , .'." , ,

... ·~ .. ~i:?~;:;;:;·'~-·: ,.~~~I'.~L~~_~L.: .~ ._.I;:T". ::-;;~;:::~~::;~·:~~::~::~'~;:.~~~;~~;;~:~~~ __ =-=;:~_:.~;~~::~~ __ ::~:.~:~~;;~~l . j PART 5: Details of legal representative (if applicable)

-if~~:~;~o;Plet~th;;;d~t8ii;':thi~~iil.;~-ih-;~~d;;;fu;·~;rvi;e~-·T~is . 'l7e8n-; .ali~~;;,~~p~;;d;;;~;frq~-:;~· V(iljb~-;~~il~- ; yoi!rJ~[I'!!repf!l.sent8tiv.e . .. ':. . .. ' .. '.: .... ". .'. . . . ... : .. :,.... i

N~;~/~o)e~;1 cos!; will b~~~id' in ~;8;io~ to ~Ppllq8tion; for prescribed ~;p~~ses !J~der.ihe V./¢i{n; Assl~~nce Scheme. : :' ~.~,>~>.~. ~:·1<.' \.: .: : . : :: ,: ". :":" "':~: ': .. ':. ',:;-' __ ... ~_~ ... __ . __ _ • __ ----.- -- ~_:.. •. - .---~~-.---~ '-"- -~-.----'-.-.'--' .- --l 18. 'Nal)1o ·of.logaJ.flrm/praclitlonor .' 'i

1~~~:~~~:!1 ~~~{~:1!f.e~:~~~.:~: ': <. :_~0~~_ :J=::::::::~:-.::=::~:.::.: .. ::-::::=:::~:::::_::.::.::~~=:::::::::-:-.::.-:::::::::.::::::::~.:::::: :::.=_-:::::::-~::.: :::.:I .J PART 6: Primary/secondary victim

PART 7: Details of the act of violence

IND.R-001739.PS.0016_R

Application for Compensation andlor Expenses 3

PART 7 (cont): Details of the act of violence

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IND.R-001739.PS.0017_R

4 Application for Compensation andlor Expenses

PART 8: Reporting the act of violence to the police

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37 .. DOY0!J h ilVll a cqpY,of th!) J;taler{leot you . . ·C.. . ' >': .. ; . . '.:'"'" ':.. • ••.. : '..: :~> ~6 ':~e~ j , ~ Please attaCh)/ lo'/hiSS', PPlicq,(ion" !;: :>?;:/ ,_ '.

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PART 9: Court proceedings (if applicable) ~-,------'---" -

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PART 10: Injuries -.",.-,-.~,""""""'~~~~., •• , •• : ••.•••• :~. ,.:, •• < ,', ............. ; ••• ~,. ' j " .• _._,

Yo.u can '9nlyclaim statutory cO.mpens.alionor.prescrit>edexpens.e$ ~(unQe.r VAS). (O[. !(ljliriJ;ls :l!s!eC!!n ·.~ched~IJ;l .1 · in the Act. . . ' ...... ,.: .... ::;.: -'.:.: . ~'.~:.': ... ; ,: :.", ~~::i.,· .: :~: :.', .. :.', ''c'~ '" :.'~ ',_ .. '. :,: .::', ... ' ~;'. -,:;::. ",'. :~'.: ' .;.', " -'::'" ,-: :.,-','" ~ ~: .. ' "',:' ·::.r;·~·:· ! .- .~ . .. -: :',,: ->: ~.' '",::-:,-:' ",,:~., -.; .... ;...... . . !

,Compensa'tion is awaroeo·for·'a maximum 'of.'thiee.injuries:'. Ttiedulislandaid .amoUI)t:~hciwn .in .lhe :Schedule is 'paid for : , ...... " ' ..... ~ ....... '\' .... , ........ ~, .. . : .. ,~ .. , ;.. ... ~ .. " ..... :. ', "., :,~""'~"",; .... ' .. ).;:: ..•... \.' ,~.! •..•... , ... ,.~ ... ,,'. " .' • ~ - ... " ' . ,

-Ilie. mo.st seriqus.·inNry:' 1 or. ,of !he ;Standa~. 'amOunt ·~qr !he .~'nd ·inp~t SilijciiJso:injury; '1109. :?%Qf·the .st<lndard amount

39. You must .nom,onat~.Hl.e c.qmp~'1s"b,e onJur!e~. you .ha)l~ (ece.lved .(lfl-'lSljffi~el.lt.$p'ace ..... ~d<:l ,an a,ttachment) ,: ": :. '. :._,_. '--:~~~:' ..... : ... ~._. _._ .. _....:_._~.~:_ .. _. _. ___ '_:~~..2."" ., .. :.<~:, .. ~_. _._ .. _. _~:..:...~~~_ \" "\'" _ i

; ~ Standard amount I Amount payable ] I : Compensable injury claimed (as described in I (if awarded :

1;------.---- (as listed !~~ .~chedule .!~. ___ . ______ .!.~~~d~!..e 1) -t--. compensation) ___ :

I ' 1. ' I $ I $ ; H \ V · j I (100% slBrld.,,1 amount)

-;---- ... ----------...... -------... ---------- i$ -------·-- I $ (10% slandard amounl) j 3. ---------------.--.. ----.------. - ---"'--1 $ -------------- r $-- ---- - i

I . ~. I (5% standard amount) I' I ' -:: :::..:~ -----..... -... -__ - .• :..::::_-==--:-.-_-_._--.:-:::. ._...:::=_:-: .. :::_-_-_ .. _-._::::~-_ .. _-.. -_:::::::.:- ::::.:~,::::_"-_-:_"'-_" -_-.... -_-.=::::::::..:.-==::.:.:: :.

IND.R-001739.PS.0018_R

Application for Compensation and/or Expenses 5

PART 10 (cont): Injuries . "',; ,~.:~'."".ii~,·:,·:···,;:·:··.!·::.n,(··.~·:·>:--·,, ~-::_~""'-":'~-: '~--:-"'I.~ ••. ,. '.' .... : .',-', ".: .. ' : ,'. '. - ••.• ,. ',',: "':, .-:~

40. Are 'you 'c!aiming 'l!:p.syc;.hologica!'or psychla~ric .i:Iis.order.~.ategory-:? ':or .. i;.ategory;2?'·.':':·\.':""':0"< :., c': ,',: ........ ·.c.:,,:·:·.

~ \~:~;i'('~1~!:i~;::!;'f;~~;~i\;~{,~*~~\;t!;:(W;)~~~:;~7~i~~;~".~:·f!+~;~~5~~~;~1J~~~g~?Fr;~~~1M{fN$;ffu;~i~:~~\· .. ,'An"I\RVV~is::a; !tHali~e.~'I?er.;Drf~~l:lo Wi.!H)~pare 's. ·wiille,n asse$.srnenCofjo\l'r.'pqnq[ti.o(J.'(O ::assis!Jl')e :compensation .

1 .·:;f:~;~~j\.~~~,;i~~~~~>~~~~~~~[;~~N~:~~t;;'h;~:t~7~[~j;i~.~r~~~i~~~~~~;r~\~m}:~:1:'1~f;~~~;ti~ ::r : ' . . ,~Noie!';W~i ARW cilHnD.Il!~th.e~i:iiepeison whoj;as 'p(O~i(ijiJ 'D; is PrQvi(iingyoit, t¥itll Cpii/ls~l/i(ig. : y'iu.cannot n~ake .

' ,_ ',:" ~ • "-"'.' ,,:.,": .. :.;. ':': ,\ •••.• -,.., ":"~';":" !"-'" . , . "" l ,;'>'" "_":" ."r. ·,'.t. '.'. . ,,";, ...... ' ....... ' .. ' ·A\.. .. ·:\ ... '. ';" . .' •••. : ...... ' •.•• ~ .•.• ; ..••• ",' :.": :'··";"·::a.n ·;app.o.mtrn¢n.t ·'to'se~ :t!lIiARW.'un'tilyolI; nomin;ltion ha.s· been. 'aPproveg.by.:victims ;>eryices. ,.:.:' .. : '.' : !

.' .... ' ... ;~-.:\~.:,:.).:,; , :'~:\.\.:,:.::.~"'. .. ~.:'-:.;:_--:._: ~ .' .. '.~ __ . .2. __ ~_._,~._._~~_:.~_. _. __ ._ . ~ . . ... 'Name'of Auth.oriseo ·Rep.o.rtWrfter ,

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--PART 11 : Monies from other sources

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You mllst.pur!iu~ :y'ow Itnlil!e,mf!nls to c;laimJrom .Other· $olJ(ce$, such a.s. work,ers 'compensatiOn., civil prolller courts, insuianqe, :elc; 'b~f9[e,:Y'ei.Jr.~?im:may' be. (ina/i~e.(1. " ..... ':" .:.... .':' .... ...... , ~ .. ':.': .< .:~ . ." ... .' '._ '~,-':" '. : . ., -.'.j . '." •• :...... .• ::'" .• '. M • '-,:" ,:",,: • " •• ~ •• :: •• :. ..::' •••• _ ". • •••••• , •• '. • •••• •

I Have you received monies, or do you intend to I II:, make a claim in relation to this matter regarding: ,I

(Please circle either yes or flO)

If you have answered 'Yes' to any question, please provide details. For example, amount already received; name of employer; insurance company; type of insurance policy; name of other party.

I: 1:]- 1 1:- 41. Workers .~~m"pensation? ~~~::"f---"--' I, I '

-------·- 1 : i ~? CiVil~~ther court claim? _, ~ L~:.sJ ____ .. _ .. ,

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~ i ' I; 43. Insurance payment or other source? I Yes I I.-~ ·. . .. .._------_._-- - _ . ... _._- ----.--

PART 12: Expenses

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IND.R-001739.PS.0019_R

6 Application for Compensation and/or Expenses

PART 13: Late applications (for compensation claims only)

PART 14: Statutory Declaration - -.;-.. "'"":':-... ..-::.,.~--.... .,.".',:.. -".: ""'" ,--;:-:-,~.-;:-~~~.,u~~7:::'~<". ....... .. ..- I

This statutory c:Jecl,ar~tion lTI\,s\;be si~oe!l 'by l/le applic,anqeijher.'lhe,'vic~m . ~r '!he,.p,erso.n ·!lpp'.lying on behalfof,the. ; victim .narTled in (,ariA) in the 'p(eseoce :of .a Justice of theP.eaqe .or &olicito.r, :'.' :'. ':, .. :;-;~". :',,: . ~'. .::. '. ". . :::::.': ~{\'if~k~~~~) ::\ '<:' ... :": ":'-"'1XA ' ; .. . .. - ~ • • . D ": ' " .' ." J :

::.;';"':.:}~:, .: .:.<, .... .:::< ":'.:.>:." .: .. ':'. '." ,'J .' , .. : . .... . . . '. h~-:--··--·-. .-~.. . .. : do solemnly 'and .sincerely, declare lha! all:the statements. made In tlJis <\ppli~lion .are lrue ·i)nd correct .to. t.he best of :

! my knowledge;' aild (make itJ!S~Qlemif~eC!qtaiion coriscientiously' ~Ueiiirig-ihesilriie. i<?·tle·tnie.:·:anC! 1?yviriue of the : I p:r~\is(~ns ,~f~~:h.~ .~~~t~~.;.j~nilOQ. :/t':::\< .-}~?' •. \', .• '··:-:·'.'.'i: Y :('.:: :.' ::: . ".'.": .: .... ,. , . ::.-:~;.:-_.: ... , .. '. :

: . : '::::. Taken 'aiiirdeclared before me at i . .

, : ... ,:.' ;) ... ,' , ...... '> ..... '-, ... ; ... ;. , ..... ,,,.', .. , i ' Peter I ruong (JP) I

. ~'(::(:}::·\~:':?X/t{;:;\~\,:::::,)\t\ i:: :-. ::J,11~~~, O(th!ll>.~ ". . .. ' .. ' ::> '.;~:~~i~~~b 10;:.'?: " ,.··:-.-,·,,, ... ···: .. · ... v···'·.··,· .. v .. ·.: :,' ::' .. ,' ... "" (signaWre) ' ..... ',., .' .. ,: ....... '· P\l.'1nli15~B7' ·" ".' ...... ,

L:·':~;,iW:;Aj:~~;i~·~f'ih~;~~~i~4#~~rliil~~~~f~(*~4~i~~ q~~~;~~~m~·~~t .": .. ': '. '" ,". '. .~~~}.4S; Application checklist

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~ :X~1!t:~6::;:;~::~~di:::;~;Z!~~~;;!3:~~~e\m·~, .... .:':.'-:... .' .' .:'. >:::':~') '.\; ~ i I :' .!·: .. ~··~·i··· "".;.:' ::' ", ~ .. :., .. :!; .. :;:.\*;~:: .. : ............ .,: .. ;." ... ":, . . '. . .... ~ .. , ',' ' ., .:'. i .. .l.Attac~: fTl e.di.c.!:II.r~J:l.~,rtsan~ :d~a~~,ec.e.~~.Ph~t'?~ jf you are claiming scarring, ' . '. . ,.. ... ': ,'. :':. ::.:. : ; I ='J, Attach ·alileceip~s. oi: .Other prool.of. ~(Cpenses .that ~aye been in\=Urred and details of any bef1efitslin~urance payments I receiy'e9 or rec~lvE!ble. . .. .. . . I ..J Attach other eyidenc~ you have 10 support your claim. I ___ . __ .. _._~. ___ ._ . __ ~. ____ .~._ _._.~ __ . ______ . __ _

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IND.R-001739.PS.0020_R