Schedule 1 "Request for an Attestation for the Purpose of Resiliating a Lease on Grounds of Violence or Sexual Assault" - Quebec, Canada

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APPLICABLE AUX COURS MUNICIPALES
SCHEDULE 1
REQUEST FOR AN ATTESTATION
FOR THE PURPOSE OF RESILIATING A LEASE
ON GROUNDS OF VIOLENCE OR SEXUAL ASSAULT
(s. 1974.1 Civil Code of Quebec)
SECTION 1
NAME
Surname
First name
 Mr.
 Ms.
How can you be reached?
 At the appended address
 Through the following person:  Ms.  Mr.
SURNAME:___________________________________FIRST NAME:____________________________
Your current address [or the address of the person indicated above]
No. and street
Apt.
Municipality
Postal code
Home telephone
Work telephone
THE DWELLING FOR WHICH YOU ARE SEEKING THE RESILIATION
1. Address
No. and street
Apt.
Municipality
Postal code
2. The owner or owner's representative
Surname
First name
No. and street
Apt.
Municipality
Postal code
Telephone (home)
Telephone (work)
3. Term of current lease
Start of lease
 lease for an indeterminate term
year
month
day
 lease of less than 12 months
End of lease
 lease of 12 months or more
year
month
day
4. Are you the only person who has signed the lease with the owner?
Yes
No
1. Who has also signed the lease with you as co-lessee?
Surname:___________________________________________
First name:___________________________________
2. What is your relationship with that person?
 spouse
 ex-spouse
 other (state):________________________________________
5. Attach a copy of the lease
1
APPLICABLE AUX COURS MUNICIPALES
SCHEDULE 1
REQUEST FOR AN ATTESTATION
FOR THE PURPOSE OF RESILIATING A LEASE
ON GROUNDS OF VIOLENCE OR SEXUAL ASSAULT
(s. 1974.1 Civil Code of Quebec)
SECTION 1
NAME
Surname
First name
 Mr.
 Ms.
How can you be reached?
 At the appended address
 Through the following person:  Ms.  Mr.
SURNAME:___________________________________FIRST NAME:____________________________
Your current address [or the address of the person indicated above]
No. and street
Apt.
Municipality
Postal code
Home telephone
Work telephone
THE DWELLING FOR WHICH YOU ARE SEEKING THE RESILIATION
1. Address
No. and street
Apt.
Municipality
Postal code
2. The owner or owner's representative
Surname
First name
No. and street
Apt.
Municipality
Postal code
Telephone (home)
Telephone (work)
3. Term of current lease
Start of lease
 lease for an indeterminate term
year
month
day
 lease of less than 12 months
End of lease
 lease of 12 months or more
year
month
day
4. Are you the only person who has signed the lease with the owner?
Yes
No
1. Who has also signed the lease with you as co-lessee?
Surname:___________________________________________
First name:___________________________________
2. What is your relationship with that person?
 spouse
 ex-spouse
 other (state):________________________________________
5. Attach a copy of the lease
1
APPLICABLE AUX COURS MUNICIPALES
SCHEDULE 1
SECTION 2
DESCRIPTION OF THE FACTS
Describe the acts of violence or sexual assault that motivate your request.
2
APPLICABLE AUX COURS MUNICIPALES
SCHEDULE 1
SECTION 3
POLICE INTERVENTION
As regards the facts that occurred, have you made a complaint to the police or has the police intervened?
YES 
NO 
Event or reference No.
Police department
Investigator
Approximate date on which the police intervened
SECTION 4
If the safety of yourself or a child living with you
-
is threatened because of the violent behaviour of a spouse or former spouse, fill out Section 4.1;
-
is threatened because of a sexual assault, fill out Section 4.2;
-
is threatened by both situations, fill out Section 4.1 or Section 4.2 and state your fears arising from the
events.
SECTION 4.1
REASONS CAUSING YOU TO FEAR FOR YOUR SAFETY OR THAT OF YOUR CHILD
BECAUSE OF THE VIOLENT BEHAVIOUR OF A SPOUSE OR FORMER SPOUSE
In your own words describe the facts causing you to fear for your safety or that of your child, based on the violence that you
were subjected to.
For example, have you experienced or are you experiencing any of the following situations: recent or imminent separation as
a couple, spouse who does not accept the separation, presence of a new spouse, accelerated degradation of the relationship,
reactions of the spouse after earlier separations, death threats from the spouse (to spouse, child, other relative), threat to
kidnap child or children, threats of suicide, armed threats, expressed possibility of homicide, harassment (shadowing,
telephone calls, letters, e-mails), spousal control, violent acts, breach of parole conditions, aggressiveness, impulsivity,
instability, desire for revenge, depression, suicidal ideation, psychological distress, obsession to be reunited with spouse,
possessiveness, jealousy, quick and unexplained change in attitude and behaviour, mental health problem, alcohol or drug
abuse problem.
YES 
NO 
Presence of children:
Presence or availability of weapons:
YES 
NO 
Do not know 
Number:
age(s):
3
APPLICABLE AUX COURS MUNICIPALES
SCHEDULE 1
4
APPLICABLE AUX COURS MUNICIPALES
SCHEDULE 1
SECTION 4.2
REASONS CAUSING YOU TO FEAR FOR YOUR SAFETY OR THAT OF YOUR CHILD
BECAUSE OF SEXUAL ASSAULT
In your own words describe the facts causing you to fear for your safety or that of your child based on the sexual assault that
you or your child has been subjected to. For example, one or all of the following situations may apply:
-
You or your child has been sexually assaulted and the perpetrator knows your address, can have access to it or,
lives or travels in the vicinity of your home (or your neighbourhood). The assault may have involved sexual
touching (genitals, buttocks, chest), exhibitionism, voyeurism, an attempt to impose sexual contact on you, threat
of sexual assault.
YES 
NO 
Presence of children:
Presence or availability of weapons:
YES 
NO 
Do not know 
Number:
age(s):
5
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