Between

A.B.

Plaintiff

and

Her Majesty the Queen

Defendant

STATEMENT OF CLAIM

Facts

(State with convenient certainty the facts on which the plaintiff relies as entitling the plaintiff to relief.)

Relief Sought

The plaintiff therefore claims as follows:

(a)

(b)

Dated at ................ the ................ day of ................, 20.......

(Signature)

Counsel for Plaintiff

(or the plaintiff himself or herself if the plaintiff acts for himself or herself)