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 ),
make oath and say as follows:
- I am the applicant.
- The facts set out in the attached application are true.
(Signature of applicant)
Sworn before me on , 19, at in the Northwest Territories (or Province of )
Commissioner for Oaths or Notary Public
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