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SCHEDULE(Subsection 3(1))

FORM A

CANADA

NORTHWEST TERRITORIES

blank line

Affidavit

I, the undersigned (given names and surname of the applicant), currently detained at (name and location of the institution) in the Northwest Territories (or Province of blank line),

make oath and say as follows:

  • 1 
    I am the applicant.
  • 2 
    The facts set out in the attached application are true.

(Signature of applicant)

Sworn before me on blank line, 19blank line, at blank line in the Northwest Territories (or Province of blank line)

Commissioner for Oaths or Notary Public

 

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