Province of ,
To the peace officers in the said (territorial division):
Whereas A.B., of hereinafter called the accused, has been charged that (state place of offence and charge);
And Whereas I have taken the deposition of X.Y. in respect of the said charge;
And Whereas the charge is for an offence committed in the (territorial division);
This is to command you, in Her Majesty’s name, to convey the said A.B., before a justice of the (last mentioned territorial division).
Dated this day of A.D. , at .
A Justice of the Peace in and for
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